Background
Optimal breast feeding (OBF) is an essential nutrition behavior proven to reduce child morbidity and mortality worldwide [
1]. It is important for immediate and long-lasting health of child; and has also maternal benefit. Foremost among these is protective of an infant from morbidity by common preventable childhood killers like pneumonia and diarrhea; thereby enhance survival [
2]. In the long run, OBF improves child intelligence and protects against long-lasting disease during adult life like diabetes. It also lowers the risk of morbidity and mortality for mothers from time of delivery to their future [
1,
2]. Hence, OBF is among most effective interventions that enhance both child and maternal health; thereby reduces health care costs and dependency which in turn promotes economic development of nations [
3]. As a result, World Health Organization (WHO), United Nations Children’s Fund (UNICEF) and Ethiopian national public health recommended to put infants to breastfeeding within one hour of birth, exclusively breastfed (EBF) for the first six months of life, and continued breastfeeding up to the age of two years to attain ideal growth, development and health [
1,
2]. However, the core indicators of OBF are still low-only 41 % of infants under-six months of age are exclusive breastfed and about 50 % of children initiated breastfeeding early globally [
4]. Similarly, only 52 % of children are exclusively breastfed and the same percent of children are initiated breastfeeding early within one hour of birth in Ethiopia [
5].
Evidences suggest that prelacteal feeding–providing any food to a newborn before initiation of breastfeeding and/or within three days after birth [
2]–is still prevalent cultural practice in many developing countries [
6‐
13], including Ethiopia [
5,
14,
15] which is a key contributor to sub-optimal breastfeeding practices [
16]. Provision of prelacteal feed to a newborn is a known barrier to continuation of EBF and early initiation of breast feeding which can lead to malnutrition [
17‐
20]. In fact, a child provided with prelacteal feeds is not exclusively breastfed. Prelacteal feeds are often provided for non-nutritional purpose mainly perceived to be useful for smoothing/clearing the throat/bowel [
15] in which butter and diluted cow’s milk/sugar are the commonest in Ethiopia [
21].
As prelacteal feeds fill a newborn’s small stomach quickly, it interferes with breastfeeding that can in turn reduces breast milk production and enhances early discontinuation of EBF that could finally encourage the provision of prelacteals. Hence, the relationship between breastfeeding and prelacteal feeding is often described as ‘Vicious cycle’ [
21,
22]. It also increases the risk of illness like diarrhea and other neonatal infections that may end up with neonatal death [
23]. Therefore, understanding factors that are associated with introduction of prelacteal feeds is essential to promote OBF that can reduce both child and maternal morbidity and mortality which in turn improves national mother–child health. However, studies on the determinants of prelacteal feeding are scarce in Ethiopia, and they have limited to specific district in the country with small sample size, thus their findings may not be representative to entire nations [
20,
21,
24]. Another weakness of these studies is limitedness to use of analytical techniques that ignores the influence of communities (neighborhoods, cities and regions) on individual decision to provide prelacteal feeds. Therefore, the current study is intended to identify individual and community-level effects on introduction of prelacteal feeding in Ethiopia using a multilevel approach, hence this deeply-rooted norm can be eliminated through a multi-level strategy that incorporates interventions at both individual and community levels. The finding from this study will help the health expertise to articulate a more effective and comprehensive intervention program, whereby intervention is not only targeted at the individual-level, but also at community-level, which in turn permits for possible long term structural change and effective policy making.
Discussion
About 29 % of children received prelacteal feeds within the first 3 days of birth which is lower than other previous studies, 41 % in Southern [
20], 45.4 % [
24] in Eastern and 80 % in North [
14] Ethiopia. The possible reason for the inconsistency with southern and northern studies might be due to study participants were only from rural community whereby they might have less access to media and health care, whereas the current study was based on national data. On the other hand, study conducted in eastern Ethiopia was based on sample of mothers-child pairs visiting the public health institutions in specific district of the country and overlooked those children at home. Otherwise, prelacteal feeding is often described as traditional practice related with birth in Ethiopia [
21]. The current finding is also lower than reports from other developing countries (35–81.8 %) [
6‐
13]. The main reason could be the difference in context, and health policy our country currently implementing which is mainly focused on prevention with community involvement about different health issues (with especial attention to mothers and infants) through implementing health extension program that works with health development army comprised of the community. Despite the implementation of such program, the current finding suggested the prevalence of prelacteal feeding is still high that could be an implication for low OBF practice in the country, indicating the need to strengthen the program in way to reduce prelacteal feeding practice.
Breastfeeding interventions involving respected members (like religious and community leaders) at each level of breastfeeding promotion programmes are suggested to promote OBF [
28,
29]. Likewise, the current study also showed the importance of involving community and religious leaders in breastfeeding promotion programs, in which there was statistically significant difference in the prevalence of prelacteal feeding practice among ethnic and religious groups. This is consistent with other studies conducted in Nepal, Laos and China [
8,
10,
30], that reported ethnicity of woman was significantly associated with mothers’ decision to give prelacteal feeds. Similarly, this is consistent with other studies findings in which some religious cultures promote the practice of prelacteal feeding [
31‐
33]. However it is not a religious practice, it is a cultural practice that originated from religious setting [
33]. Thus, ethnicity and religions could have their own found on initiation of traditions like practice of prelacteal feeding. Nevertheless, this finding indicates that there is a need to focus on community and religious leaders as information on infant feeding provided by both ethnic and religious group leaders could be more likely to be accepted and changed to practice especially in case of Ethiopia.
The current study also revealed that, the higher household economic status was negatively associated with introduction of prelacteal feeding. This finding is in-consistent with studies conducted in Vietnam and Nepal [
22,
34] that reported high socioeconomic status promotes introduction of prelacteal feeding. This could be because of the difference in culture on preferring type of prelacteal feeds. In these studies prelacteals used were costly to be used by lower socioeconomic status; hence only those mothers from high socioeconomic status bought and fed their newborn. However, butter and plain water were more commonly provided prelacteals that can be easily accessible to majority of Ethiopians. Besides, it could be also explained by the fact that higher proportions of women from higher socioeconomic status (SES) are educated and possibly discouraged prelacteal feeding than those from lower SES according to EDHS 2011 report [
5].
Giving birth on the hand of health personnel had a negative effect on introduction of prelacteal feeding in the current study, which is consistent with other studies in India and Bolivia [
12,
35]. This could be because mothers who delivered on hand of health personnel are more likely to be encouraged and counseled for healthy infant feeding practices. In line with other studies in Egypt, Kuwait and Nigeria [
7,
36,
37], the current study also reported cesarean mode of delivery was associated with higher odds of prelacteal feeding. Initiation of breastfeeding within 1 h of birth was associated with lower odds of the introduction of prelacteal feeding. This is consistent with reports of several studies [
7,
17,
37]. This might be because those mothers who are late on initiation have miss-perception on colostrum feeding and/or have cultural practice to feed other than breast milk, thus more likely to feed prelacteals. The current study also found that lower size of child was important factor that encourages mothers’ decision to give prelacteal feed, which is consistent with findings of study conducted in Egypt [
7]. This could be due to the miss-perception by mothers in which the lower size births could benefit from feeding their newborn with feeds other than breast milk and/or miss-perception that only breast milk can’t meet the nutritional need of the newborn.
The characteristics of community where a woman is living have a significant positive or negative effect on her decision to feed her newborn. The current study found that living in different contextual regions showed significant difference on women decision to introduce prelacteal feed, that is consistent with finding of study in Nepal [
34]. This could be explained by difference in living situations, and access to health facilities, media and information across regions. Therefore, this finding indicates that there is a need to focus on reducing differences in access to health care and information while implementing breastfeeding promotion programs.
Antenatal care visit is a best opportunity to promote skilled attendance at birth, and to counsel and educate mothers on essential healthy behaviors like newborn feeding; hence mothers who have visit were more educated or aware of these healthy behaviors and discourage prelacteal feeding [
38]. Likewise, as there is higher number of women who visited ANC in a community, the more likely to develop a norm that discourages prelacteal feeding. This effect was indicated by the current study in which living in the community where there is high ANC use discouraged the mother to feed prelacteal to their newborn. Generally, reaching women with health education (counseling) and strengthening the community involvement that currently the government of Ethiopia implementing to increase maternal and child health service coverage can increase the OBF practice and discourage traditional feeding practices like prelacteal feeding.
The current study found that; even if most variation on introduction of prelacteal feeding was explained by individual-level factors, substantial proportion of variation in prelacteal feeding practice was also explained by unmeasured community-level factors. The random effects of the community-level were significant in explaining the prelacteal feeding practice even though it reduced in full model, from 39 % in null model to 26.7 % in full model. This indicates the community-level effect was high and mothers’ decision on giving prelacteal feeding was explained by both individual and community-level factors. However, since the unexplained community variance was still significant after controlling for community variables in the combined model further study should be designed to explore additional community-level factors, and factors evidenced to have effect but not included in this study like knowledge of mother towards breast feeding.
Strengths and limitations of the study
The current study was conducted by using a multilevel analytical approach that can able to identify the multilevel determinants of introduction of prelacteal feeding and provides important insight to design most appropriate multilevel interventions. Moreover, the results are representative of the entire Ethiopian population because appropriate estimation adjustments such as weighting, accounting for sample design were applied for analysis. Thus, it is the first nationally representative study to report on multilevel factors associated with the introduction of prelacteal feeds. It is also the first to examine the influence of ethnicity and religion on mothers’ decision to give prelacteals to their newborn in Ethiopia.
Despite its strength, the findings of the current study should be interpreted in light of its limitations. Analyses are based on multilevel logit models with random (varying) intercept and fixed coefficients only. Hence, the findings cannot provide evidence of the effects of individual factors variance across communities. The data was collected based on recall that may increase the risk of recall-bias. Finally, EDHS did not collect some information such as maternal beliefs, miss-conceptions and knowledge towards breastfeeding that were evidenced to influence introduction of prelacteal feeding [
22,
39], thus their effect was not controlled and seen in this study that might lead to residual confounding.
Conclusion
The current study showed that the prevalence of prelacteal feeding is high that remained a challenge for optimal breastfeeding in the country. Not only individual-level factors, but also community-level factors contribute to the high prevalence of prelacteal feeding practice. About 39 % of variation in introduction of prelacteal feeding was explained by community-level effects. At individual-level, low socio-economic status, caesarean mode of delivery, giving birth at hand of non-health personnel birth assistance, late initiation of BF and low birth size of child encourage prelacteal feeding practice. In addition, this study also evidenced that there was significant difference in prelacteal feeding practice among ethnic and religious groups. At community-level, low community ANC use encourages introduction of prelacteal feeds, and significant variation in prevalence of prelacteal feeding was also seen across regions. The government should therefore focus in increasing access to health education through increasing maternal health care service coverage and community involvement to increase optimal breastfeeding practices.
Competing interests
The authors declare that they have no competing interests.
Authors’ contributions
AB, ABK, YG have made substantial contributions to conception, design, analysis and interpretation of data; AB, ABK, YM involved in drafting the manuscript, revising it critically for important intellectual content; and all have given final approval of the version to be published.