Background
Global rates of exclusive breastfeeding have remained stagnant since 1990 with only 36% of children aged less than 6 months exclusively breastfed in 2012 and with only slight increment in year 2016 (i.e. 40%) of children less than 6 months exclusively breastfed [
1].
In developing countries, there are approximately 56 million infants less than 6 months of age, approximately 22 million are exclusively breastfed, while over 34 million children are not [
2]. Eighty percent of these children who do not benefit from exclusive breastfeeding in developing countries live only in 29 countries. From these 29 countries, the 10 large countries including Ethiopia have two-thirds (over 21 million) of the approximate numbers of non-exclusively breastfed children in developing countries [
2].
In a pastoralist area such as Afar, one in five children suffers from acute malnutrition. The high rate of malnutrition contributes to the country’s elevated under-five mortality rate of 88 deaths per 1000 live births, with malnourishment accounting for over half of all under-five deaths. Prelacteal feeding, bottle feeding, discarding of the colostrum, and other cultural taboos play a significant role in poor caring and feeding practices. Health service coverage is limited while antenatal care in Afar (19.2%) is well below the national average (52.1%) [
3].
The Afar region ranks top among all regions of Ethiopia regarding having the highest number of stunted and wasted children. According to the Ethiopian Demographic Health Survey (EDHS) 2011, the Afar region has the lowest exclusive breastfeeding median duration which is 0.6 months [
4] next to Somali 0.5 months, which is again far beyond the national median duration of 2.3 months.
On top of that seasonal variances in food consumption, water availability, sanitation, and breastfeeding practices are poorly understood but contribute greatly to the prevalence of malnutrition in Ethiopia and particularly in Pastoralist areas such as Afar [
3]. The main reason why there are such seasonal variation particularly in our study area is frequent changes in the climatic condition. These changes are often followed by drought [
5].
Investigation of the prevalence and associated factors of EBF may provide insight into the current burden and nature of the problem and help on how to direct prevention strategies. Although several studies have been conducted on EBF in many regions of Ethiopia, the EDHS with limited factors remains the only study that was carried out on the specific area, which clearly suggests that there is a wide research gap on the study area. The aim of this study was to measure the prevalence and identify associated factors of exclusive breastfeeding practice in Afar.
Methods
Study design and population
A community based cross-sectional study with focus group discussion (FGD), i.e. with healthcare providers and parents, was conducted from March, 2015 to April, 2015. Mothers with infants under the age of 6 months from pastoral and agro-pastoral Ethiopia; Aysaita, were eligible to participate in the study. Aysaita is 655 km from Addis Ababa and 65 km from the capital city of Afar, Samara. According to the 2007 Census conducted by Central Statistical Agency (CSA) of Ethiopia; the total population of Aysaita was 55,519, whereas the total population of under five and under 1 year was 7645 and 1654 respectively and a total households (HH) of 9740. About 91.7% of the population lives in rural areas; pastorals and agro-pastoral system of livestock production is the dominant source of livelihood.
Sample size determination and allocation
The required sample size was determined based on a prevalence rate of 52% of exclusive breastfeeding infants under 6 months of age from the national EDHS 2011; with 5% level of significance, 5% margin of error and 10% non-response rate; yielded 383. We used single and double population formula to accommodate the objectives of the study. The sample size was inflated with a design effect of 1.5 and the total sample size reached 631. Samples were allocated proportionally across clusters using the Expanded Program for Immunization (EPI) sampling technique.
Sampling procedures
Quantitative sampling procedure
Aysaita woreda (woreda is a district and the third-level administrative division of Ethiopia) has a total of 9740 households (HH), 13 kebeles (wards or neighborhood associations, which are the smallest unit of local government in Ethiopia), two urban and the remaining 11 rural kebeles. The kebeles with their respective live infant population are; Kebele 02 (265), Kebele 01 (297), Kerebuda (100), Berga (79), Keredura (67), Mamula (109), Henele (99), Henedegi (111) Gaharetu (69), Galefagi (143), Romayity (81), Galealo (69) and Ehahile (164). To select the representative data this study aimed using modified EPI cluster sampling.
A selection of HHs within a community should ideally be random and in practice this is most closely achieved by systematic selection from a numbered list of HHs. In many situations like this specific research however there is no list or map for HHs available. We didn’t have a resource to completely enumerate or map all the HHs in the community and so some compromise must be used. As up to date information on the total estimated population was difficult to obtain and as simple random sampling was almost impossible to accommodate due to unavailability of list of all the HHs and a resource limitation, the investigators found the modified EPI cluster sampling scheme [
6] to be a useful alternative approach. The modified EPI cluster sampling method is a type of cluster sampling developed by the WHO expanded program for immunization to estimate vaccination coverage. This procedure led to the selection of clusters and HHs.
First stage sampling: Cluster selection
Population proportion to size (PPS)
The PPS sampling method led to selection of clusters/kebeles, so that each household had equal probability of being selected in the sample. This procedure is self-weighting. Accordingly, selected clusters were 02-kebele, 01-kebele, Kerebuda, Mamula, Henele, Galefagi and Ehahile.
Second stage sampling
After selecting the seven clusters which were then were called enumeration areas (EA), the second stage to be carried out was a method on how much HHs to allocate for each EA’s to acquire the calculated sample size of 631. As all the clusters are selected proportional to their size, we found it appropriate to divide and distribute an equal number of HHs for each EA’s. Dividing 1958 HHs (estimated HHs to be visited) equal to the 7 EAs, we found a number, 280, and 280 HHs in each selected cluster or EAs were visited.
Household (HH) selection
Selecting the first and the consecutive HHs
These involved two stages, a method of selecting the first household (HH) to be the starting point and a method of selecting the successive HH after that. To select the first HH we used the EPI recommendation for selection of the first HH. That was, we chose a central point in the village (a market), and then we chose random direction from that point, counted the number of HHs between the central point and the edge of the town and randomly selected one HH to be the starting point. The remaining HHs were selected in order of giving us a wide spread coverage consistent with practicality. According to the EPI strategy we went to the HH whose door was nearest to the door from the HH we stood up.
Qualitative sampling procedure
Before conducting the focus group discussion (FGD) we did a situational analysis in order to help us on selection of our participants. The key informant was a case team leader for maternal and child health and a supervisor assigned for Aysaita woreda health bureau from the regional health bureau. He was a person in a position to know the healthcare providers in the woreda very well. The key informant suggested for one group of health professionals FGD, as it would be infeasible to make a number of professional groups. Because most professionals were working on the rural kebeles, it was found to be difficult to call-upon healthcare providers from all the kebeles and conduct a number of different group discussions. The reason was; if they were to come up to one location together it would make them leave their duties and one health post has a maximum of two health professionals, excluding HEW i.e. a health officer with/without one nurse or two nurses). It was suggested to call-upon the professionals that were found on the urban and the nearby rural kebeles, so that, we have tried to include different health professionals and limited our FGD to one.
The same was true for the other FGD. It was suggested to limit it to one FGD. Limited means for transportation to the rural kebeles and finding enough translators were the main challenges from the key informant location, which hindered us from conducted more FGDs. Accordingly, we were obliged to limit our sample selections from the mothers and fathers who came to the health facilities. We have conveniently selected mothers and fathers while they came to the health facilities (three health facilities) for healthcare treatment and we selected one traditional birth attendant with the suggestion of HEW (a participant on the healthcare professional FGD).
In order to minimize the possible bias that the key informant may have on selection of the participants, in our explanations we made sure to emphasize that we want a group of people that can express a range of views, to be able to have a proper discussion.
We have tried to create a smooth discussion environment and tried to encourage the communication and interaction during the FGD in every possible way we could.
-
We have tried to hold the FGD in a neutral setting which encourages participants to freely express their views.
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We made sure that there were no disturbances, sufficient quietness, adequate lighting, adequate ventilation as it was the hottest season and also there were hot and cold beverages (liquid refreshments) including water.
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Materials that were necessary to conduct the FGD were prepared prior (i.e. FGD guide line, double voice recorders and note books, pen and pencils).
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We have also arranged the chairs in a circle so that we are able to create conducive discussion area.
Selection of participants for the healthcare providers FGD
The Aysaita Regional Health Bureau (ARHB) reported that the district has one hospital, one health center, 10 health posts, and four private clinics. Employees in the health centers and health posts were a total of 87; 32 were technical and the other 55 supportive. There was a total of 20 health extension workers in the woreda, and all 20 working in the rural setting. We made our selection from the HC and HPs and from the woreda health bureau. With the help of the of the key informant we selected eight healthcare professionals. Accordingly, we selected one administrator (public health expert with educational background), two nurses, two HOs and three HEW from Aysaita HC which is located in the urban and nearby rural HPs (Henele, Berga and Ghalefage).
Selection of participants for community FGD
We conveniently select a total of fiv5 mothers and 4 fathers from urban and nearby rural kebeles (2 mothers and 2 fathers from Kebele 1 & 2 and 3 mothers & 2 mothers from Henele kebele), while they came for healthcare treatment to Aysaita Health center and Henele Health post. Although we couldn’t be able to know the specific number of available traditional birth attendant, with the recommendation of one of the participants in the healthcare professional FGD, a health extension worker, we selected one traditional birth attendant.
Data were collected using a structured interviewer administered questionnaire and focus group discussion guide.
The questionnaire
A questionnaire with both closed and open-ended questions was used to collect information on infant characteristics (sex and age), maternal demographic characteristics (age, education and marital status), maternal socioeconomic characteristics (occupation income, and ownership of items), maternal attitude and knowledge on breastfeeding [
7‐
10], sources of breastfeeding information, maternal delivery experience and infant feeding practices. The questionnaire was adopted from the EDHS, WHO and related studies. The questionnaires were initially prepared in English and then translated into Amharic and Afar. The Afar version was again translated back into Amharic and English to check for any inconsistencies or distortion in the meaning of words and concepts.
Focus group discussion guide
A focus group discussion (FGD) guide was used to elicit information on infant feeding practices with special focus on knowledge, attitudes and beliefs about exclusive breastfeeding and factors influencing the practice of exclusive breastfeeding. This information was intended to provide an in-depth understanding of infant feeding practices as well as offer an understanding or explanation of the quantitative findings. The FGD included mothers/caregivers, fathers, grandparents, healthcare providers and traditional birth attendants and the group included both rural and urban participants. Two FGDs were conducted with 8 to 10 participants in each group. The primary investigator (PI) together with a translator took the primary lead in eliciting the questions and modulating the discussion.
Operational definitions
Exclusive breastfeeding: Was measured using a single 24-h recall method where by mothers are asked if they fed their baby only with their breast milk (including milk expresses from a wet nurse), ORS, drops, syrups (vitamins, medicine and minerals) and nothing else in the last 24 h prior to the interview.
Predominant breastfeeding: Fed on breast milk (including milk expressed or from a wet nurse) certain liquids (water, water-based drinks fruit juices), rituals and ORS, drops or syrups (vitamins, medicine and minerals) as the predominant source of nourishment.
Partly fed: Breast milk (including milk expressed or from a wet nurse), any food or a liquid including non-human and solid or semi-solid foods milk and formula.
Complementary breastfeeding: Fed on breast milk and complementary foods (milk, porridge, semi-solids or solids).
Non-breastfed: Not fed on breast milk.
Knowledge score about EBF
There were 10 questions (5 general questions and 5 maternal and child related questions) for assessing knowledge adopted from related studies. An average of responses on knowledge variables was done by computing variables and mothers who scored less than the average are labeled to have poor knowledge and those scored above as having good knowledge.
Attitude
Four scaled Likert scale was used to measure the opinions of mothers towards EBF. All attitude opinion variables were computed and averaged. Those scored below the average were considered with negative attitude and those scored above the average were considered with positive attitude.
Data quality management
The quality of data was assured before, during and after data collection process.
Before data collection
Objective based and standardized designing of questionnaire, preparation of data collectors training manual, experience-based selection of data collectors and finally training of data collectors (10 in number) and one supervisor on sampling procedures, techniques of interviews and data collection process and giving of training manuals and actual training was performed. In addition, the data collectors and supervisors were participated in pre-testing of the questionnaire for its understandability by 5% of sample on volunteer individuals in kebeles which were not included in the actual data collection. The purpose of the pre-test was to ensure that the respondents be able to understand the questions and to check the wording, logic and skip order of the questions in a sensible way to the respondents. Amendments were made accordingly after the pretest.
During data collection
The supervisors and principal investigator were closely following the day-to-day data collection process and ensure completeness and consistency of questionnaire administered each day.
After data collection
The collected information was rechecked for its completeness and consistency by the supervisors and principal investigators before transferring in to computer software. Non-over lapping numerical code was given for each question and the coded data were entered and cleaned into SPSS software Version 21.
Data analysis procedures
The collected data was checked for completeness and entered to SPSS version 21 statistical software for each specific objective step wise. According to the specific objectives, descriptive statistic including Proportion, frequency distribution, Mean (SD) and Median was used to describe the data on the sample population in relation to relevant variables.
Bivariate analysis; cross tabulations was done to see the association between the explanatory and outcome variables. Multivariate analysis; Binary logistic regression model was employed by selecting only variables that appeared to be statistically significant at (p < 0.05) in the bivariate analysis. A thematic content analysis was used for analyzing the qualitative data’s using Open code software application and data and environmental triangulation were done, which allows for different stake holders on exclusive breastfeeding (i.e. mothers, elders, fathers, traditional birth attendants and healthcare professionals) to participate and there by maintain the validity of the results. Also, the FGD included participants both from urban and rural areas so as to have a better understanding if residence has effects on proper EBF practice. Finally, the data was presented with appropriate tables, diagrams and figures.
Household wealth was assessed by constructing an index using Principal Component Analysis (PCA). The domains to construct the model include characteristics of the house including floor, wall, roof, type of toilet facility, source of water, ownership of agricultural land, ownership of an animal including goat, camel, sheep, chicken, donkey, ox and cow, ownership of fixed assets such as; motorcycle, car/truck, television, cell phone, phone, refrigerator, clock, bed and main source of fuel for cooking. Cut-off points were used to divide the data into three equal groups; low, medium and high, resulting in quintiles representing the wealth status of the households.
Discussion
This study attempted to determine the prevalence of EBF, knowledge about EBF practice, attitude towards EBF and associated factors of exclusive breastfeeding practice. The prevalence of ever breastfeeding was 97.6% while the crude prevalence of exclusive breastfeeding for infants under 6 months of age was 55%. In the multivariate analysis, urban residence, good knowledge about EBF, delivering at health facilities and low parity were found to be associated factors for exclusive breastfeeding among the infants aged less than 6 months.
The majority of mothers (97.6%) breastfed their babies. This result is comparable to the EDHS 2011 [
4] whereby the rate of infants ever been breastfed in the country was 97.5 and 97.7% for Afar region, respectively. The prevalence of other regional states in Ethiopia ranges from 93.4% in Addis Ababa to 99.1% in Dire Dawa which was comparable with this study finding. The qualitative study also reveals that breast feeding is a common practice in the community, one of the TBAs stated that ‘
a women is obliged to breastfed her baby until at least 2 years and it’s our culture’.
Although the World Health Organization (WHO), global and national infant and young child feeding guidelines recommend that all newborns should be exclusively breastfed their infants for the first 6 months [
11], the crude prevalence of exclusive breastfeeding in this study was 55%. This was lower than studies done in Jimma town (60.1%), Goba district (71.3%), Ghana (64%), Nepal (66.6%) [
12‐
15] and while higher than the finding from EDHS 2011, Arjo woreda, Jimma, Bahirdar [
4,
7,
16] whereby the prevalence of exclusive breastfeeding were 47.9, 52, and 49.1% respectively. This difference is expected as the residents in our study area are part of a pastoral community. The study area is in a different setting than Bahirdar or Ghana where people are bound by number of traditional practices in day-to-day life and appear to be closed to evidence based facts. Also, as the study area is one of the regions where infrastructure such as electricity and roads is still under development, unlike Bahirdar and Ghana. Electronic based information such as advertisements, NEWS, announcements from the ministry of health or the regional health bureau might not be accessed. Also, availability to health services will be less which again hinders access to services like counseling, contributing to the low prevalence of exclusive breastfeeding. The high numbers are attributed may be because it’s a norm and a tradition to breastfed the babies in the community of Afar and that might contribute to the relative high prevalence of exclusive breastfeeding.
The month-specific prevalence of exclusive breastfeeding decreases as the age of the babies increases 62.8, 61.8 60.6% at age < 1 month (babies in the age range of 0–29 days, 0–3 months (babies in the age range of 0–89 days) and 4–5 months (babies in the age range of 120–149 days) respectively. In the age range of 5–6 month (i.e. babies in the age range of 150–179 days) the prevalence dramatically drops to 17.2% (See Fig.
1). This finding was more or less comparable with a study finding in Jimma where by the prevalence was 67.2, 24.3 and 8.4% at age ≤ 2 months, 3–4 months and > 4 months, Nepal [
15] which showed that the prevalence of exclusive breastfeeding were 74, 24% and EDHS, 2011 [
4] 70, 55, and 32% at 1 month, 3 months and above 4 months, respectively. As infants grew older and older, the prevalence of exclusive breastfeeding decreases significantly indicating the overall lower duration of exclusive breastfeeding in the study community. This is common in many developing countries as majority of mothers believe that breast milk alone was not sufficient as the age of infants grew older, mothers might have introduced complementary feeding for their infants due to the assumption that breast milk alone would not satisfy their needs as the infants are already older. Most of the mothers in the FGD described that they started to give their children cow milk at age of 3 months because they believe that only their breast milk was not enough. Traditional birth attendants also noted the babies are too small to survive only with breast milk and they advise mothers to give them light food especially if they are crying and if they are not gaining weight
.
The possible explanation for the relatively high prevalence of EBF might be due to the fact that postpartum care is traditionally given in the first few months after birth where mothers remain at home, creating a chance to exclusively breastfeed their infant.
This study found a significant difference between mothers who resided in urban areas versus rural areas with regard to exclusive breastfeeding. Children of mothers who reside in urban areas were found to positively associated with EBF. This result is in line with studies done in Ghana, Awi, and Malawi [
14,
17‐
19]. Many different reasons might explain these results. One likely reason might be that mothers who resided in urban areas might have better access to health facilities where they can take advantage of appropriate counseling and care for EBF. Another reason is that it is known that mothers in Afar have a lot of traditional practices concerning child care as one of the TBA witnessed the moment the child is born they nourish the baby with a drop of water
. Traditional practices are often less prevalent in urban areas than rural areas possibly because the additional exposure and access to health, services and information through different media in urban areas. This access could be influencing women in urban areas to adopt new practices that maintain exclusive breastfeeding. Other possible reason would be, people in rural areas live a life characterized by lots of hardships due to lack of infrastructures, that led them to different works that requires physical strengths, and less access to services such as clean tap water, road, health service, electricity unlike the urban residents [
15]. This might leave mothers to have less time to exclusively breastfeed their child as they share most of the responsibility for home works (i.e. fetching water, cleaning, cooking, taking care of the baby and etc.).
The majority of mothers in FGD also identified their husbands left them alone moving with the camels for food and water to a remote village where they can get a water and grass for camels and they have to do everything by themselves and couldn’t be able to breastfeed their babies as they want to.
Lack of nearby health facilities and poor road infrastructure makes it challenging for mothers in pastoral communities to travel to seek out the counseling and health education services about infant feeding that are delivered through these facilities. This is also supported by our FGD. Fathers and health extension workers reported that there should be more health extension workers in the rural areas as the villages are dispersed and health facilities are not in every village and as the health extension workers can only reach in the nearby villages.
In the current study, knowledge of mothers on Exclusive breastfeeding was 50.2% which is comparable to the study done in Jimma town (53.7%) but lower than the study finding in Malaysia (74.8%) [
20]. This difference might be attributed due to the difference in awareness level about breastfeeding practice. Qualitative finding also indicted that even though health information dissemination is one of the targets of the ARHB and a work in progress there are still mothers who don’t have sufficient knowledge about EBF.
Being knowledgeable on the right time to initiate breastfeeding and complementary fluids and foods was positively associated with EBF. This finding was in line with many studies; Jimma, Taiwan, Tanzania [
12,
21,
22]. This result is expected and the general explanation will be that the significance of having good and bad knowledge expected to have a direct effect towards a practice and the ARHB should continue to work on policies that encourage the availability of knowledge.
This study found that 66.2% showed favorable/positive attitude towards exclusive breastfeeding which was consistent with the study finding in Jimma town (73.9%) had positive attitude towards breastfeeding practice [
12]. Although, in this study the attitude towards breastfeeding was generally favorable, > 24% respondents agree on discarding the colostrum before giving the first breast milk. This is probably due to insufficient knowledge on the issue, and attitude towards EBF is not associated in the bivariate analysis.
Having one, and two to four pregnancies was found to be associated with EBF, which is consistent with a study done in Jimma, whereby mothers having two and below children were more likely to practice exclusive breastfeeding.
Furthermore, the study found that a higher proportion of women who delivered at a government health facility exclusively breastfed compared to women who delivered at their own home or the home of the TBA. Place of delivery has been found in a number of studies to be associated with exclusive breastfeeding. In the present study, delivery at a government health facility was identified to be associated with exclusive breastfeeding and this conforms to studies in Ghana [
14]. The association between delivery at hospital and exclusive breastfeeding can be attributed to the call made by WHO and UNICEF [
11,
23] for hospitals to be centers of breastfeeding. This initiative, undoubtedly, might have accounted for government health facility being a predictor of exclusive breastfeeding in the country even though some health facilities may not have fully implemented the WHO recommendations. The findings of this study contrasted those of a study done in Nepal [
15], where mothers who gave birth at home were more likely to practice exclusive breastfeeding. This is probably due to the fact that in Nepal, mothers who gave birth within health facilities are those with higher income and education, as health facilities are not equally accessible to all mothers. The situation is different in Afar, as public health facilities are relatively highly accessible for all regardless of income and educational status.
Limitations and strengths
This study can be interpreted in light of its strengths and limitations. The use of validated questionnaires, both quantitative and qualitative methods of data collection and data triangulation, the fact that this study did assess individual factors; including knowledge and attitude of mother, as well as variables related to families and choosing and accommodating the study in remote and pastoralist area, Afar, rarely chosen place by researchers of any stream can be consider as major strengths of this study.
However, the 24-h recall to determine exclusive breastfeeding practice, an assessment method in which some infants who were given other liquids regularly may not have received them in the last 24 h before the survey, may have overestimated of the proportion exclusively breastfed. Many studies have shown that a large proportion of infants who were exclusively breastfed in the previous 24 h were either not exclusively breastfed during the previous 7 days, and/or, not exclusively breastfed since birth [
24,
25].
Other factors like infant’s birthweight, antenatal care follow up, health status of the mother and the child and other factors which might be associated with exclusive breastfeeding were not addressed in this study. In addition, the lack of published articles on breastfeeding practices in pastoral areas could be mentioned as a limitation. Furthermore, this study used a cross-sectional study design, which made it difficult to establish causal effect relationship.
Limiting the qualitative study, due to various reasons, only having two focus group discussion can also add to the limitation of this study.
Conclusions
Even though the crude prevalence of infants younger than 6 months who were ever breastfed was high, the prevalence of exclusive breastfeeding did not meet the WHO recommendation. In the current study, however half of the mothers had good knowledge about exclusive breastfeeding, knowledge of mothers about the right time to initiate breastfeeding after birth, and knowledge about foods/liquids recommended to infants less than 6 months was far lower in many studies done in developing countries. Most of the study population had positive/favorable attitudes towards exclusive breastfeeding practice during the first 6 months. Urban residence, having a good knowledge about EBF practices, low parity and delivering at health facilities were found to be associated with exclusive breastfeeding practice in the studied community. In addition, the qualitative inquiry revealed that mothers have a poor understanding of what constitutes EBF (i.e. what it means and for how long it is recommended). It is also revealed that traditional beliefs, myths and misconceptions about exclusive breastfeeding, perceived insufficient breast milk production, lack of support from husband and family, mother’s dependency on husband’s income, mothers having high burden of work in the home, inadequate number of healthcare providers and lack of properly addressing EBF in the health education packages for mothers, are all found to be barrier factors for proper EBF practice.
Thus strengthening efforts to enhance the infrastructures (i.e. road; so that health facilities are easily accessible for antenatal visits, delivery and counseling, electricity; for simpler life style and for easy information access through media, tap water; so that it will not take longer time for women to fetch water, health facilities; as health facilities are not still available for most of the rural villages and the dispersed placement of the pastoral community), promoting health education that are more specific on the importance and proper EBF practice; using accessible means such as medias and public meetings, elder, religious and influential persons, revising health education packages contents and delivery modalities, encouraging mothers to deliver at health facilities, creating income generating mechanisms for mothers to support themselves and their families; specially work on education strategies to combat the traditional beliefs, myths and misconceptions about EBF; such as apply trials to replace the traditional practice in a way that is not interfering with proper EBF practice, train more healthcare providers and revise means to reach the community, such as mobile clinics as the pastorals move from place to place and encouraging further research on the topic of area with objectives that will help on exploring on ways to are recommend for hand express milk and or explore to distribute the workload of the household are recommended.