Trends and determinants of early initiation of breastfeeding and exclusive breastfeeding in Ethiopia from 2000 to 2016

Optimal breastfeeding is the best source of nutrition for the newborn and the cornerstone for establishing a healthy growth and development for children [1, 2]. Optimal breastfeeding is beneficial to the infant, the mother, the household and the community. Optimally breastfed babies are less likely to develop childhood infections (such as diarrhoea, otitis media and pneumonia) [2‐4]. In later life, optimal breastfeeding is associated with a reduced risk of overweight or obesity and type 2 diabetes, and a higher cognitive function has been demonstrated among children who were exclusively breastfed for up to 6 months [1]. Mothers who optimally breastfeed have a reduced incidence of type 2 diabetes mellitus, breast and ovarian cancers [5‐7]. They are also more likely to have improved birth spacing and social-emotional interaction with their babies [8]. At the community level, good nutrition of children contributes to improved human capital through a reduction in expenses on infant formula and increase opportunities for a more sustainable future [9].

In view of the benefits of optimal breastfeeding, the World Health Organization and the United Nations Children’s Fund (WHO/UNICEF) [10] recommend early initiation of breastfeeding within the first hour of birth and exclusive breastfeeding (EBF) for the first 6 months of life, as well as continued breastfeeding until the child is 2 years of age [11]. However, current evidence suggests that approximately 38% of infants are exclusively breastfed worldwide [5], while timely initiation of breastfeeding varied globally, higher in high-income countries than low and middle income nations [1]. More recently, the United Nations renewed its commitment to improving child nutrition (including breastfeeding outcomes) worldwide through the United Nations Decade of Action on Nutrition (2016–2025) [12] and the Sustainable Development Goal (SDG-2.2) of ending all forms of malnutrition [13].

In low and middle income countries (LMIC, including Ethiopia), where access to clean water, adequate sanitation, and basic health and social services are often limited, the effects of suboptimal breastfeeding are even more prominent [9, 14]. For example, a recent study from Nigeria indicated that an estimated 23% of diarrhoea deaths among children under five were attributable to suboptimal breastfeeding in 2016 [15]. In Ethiopia, many subnational reports indicated that early initiation of breastfeeding (66.5%) and EBF (60.1%) [16] were well below the Ethiopian Health Sector Transformation Plan (HSTP) target of 90 and 72%, respectively [17]. Additionally, a systematic review of mostly subnational studies reported that government employment, having formal education, being knowledgeable, receiving guidance and counselling from health care workers, giving birth at a health facility and vaginal delivery were common factors associated with a higher practice of early initiation of breastfeeding and EBF in Ethiopia [16]. Although useful, these studies have the following limitations: (i) generalizability of the results due to increased heterogeneity of the study methodology, and under or over representation of some geographical regions [18‐21]; (ii) trends in early initiation of breastfeeding and EBF were not examined to guide current and future efforts; (iii) limitations in the statistical analyses (such as adjustment for confounders and ignoring hierarchical nature of the data) [22, 23].

Understanding where progress has been made, where to allocate additional resources and who to specifically target to increase breastfeeding outcomes can provide insights into opportunities for scale-up and/or refinement of breastfeeding programs in Ethiopia. Such information would be useful to Ethiopian policy decision-makers and public health practitioners in providing specific policy interventions given the revitalized global efforts to improve child nutrition and end all forms of malnutrition. Accordingly, the present study aimed to examine the trends and determinants of early initiation of breastfeeding and EBF in Ethiopia between 2000 and 2016.

The present study indicated that early initiation of breastfeeding increased from 48.8% in 2000 to 75.5% in 2016, potentially reflecting the impacts of the national infant and young child feeding strategy in Ethiopia [36]. The study also found that EBF improved from 54.5% in 2000 to 59.9% in 2016, but this was not statistically significant. Between 2000 and 2016, maternal informal employment, frequent ANC visits and cesarean delivery were associated with delayed initiation of breastfeeding, while delivery at a health facility and residing in the metropolis region were associated with a higher prevalence of early initiation of breastfeeding. In the combined data, informally employed mothers and those with four or more members in the family were more likely to exclusively breastfed their babies. In the 2016 data, maternal formal employment, giving birth at a health facility, and residing in the metropolis region were associated with early initiation of breastfeeding. In similar data, frequent ANC visit was associated with EBF, while those resided in metropolis region were less likely to exclusively breastfed.

During the MDG period (2000–2015), which is almost similar to the study period, maternal employment and region of residence were the common factors associated with both early initiation of breastfeeding and EBF in Ethiopia. The odds of engaging in early initiation of breastfeeding was lower among mothers who were informally employed; however, EBF prevalence was higher in this group. The relationship between informal employment and early initiation of breastfeeding could probably be explained by poor awareness and unfavorable sociocultural practices (like prelacteal feeding) that is common among mothers employed in agricultural or manual works [37]. Globally, there is variation in the literature about the influence of maternal employment on the early initiation of breastfeeding. For example, employed mothers from Nigeria [28], Namibia [38], and Pakistan [39] were more likely to delay initiation of breastfeeding compared to mothers not in employment. Evidence from India, nonetheless, suggested that employed mothers were less likely to delay initiation of breastfeeding [40]. The relationship between maternal informal employment and EBF might be explained by the flexible working hours that mothers in the informal sectors have as it allows them to breastfeed their babies on demand [41]. However, subnational studies conducted in Ethiopia indicated that maternal employment was associated with lower odds of exclusive breastfeeding EBF [42, 43]. Evidence from the Middle East [31, 44] was consistent with our finding, where mothers informal employment or working outside their homes were less likely to engage in EBF compared with those in informal employment.

Mothers from the three metropolitan regions (Addis Ababa, Dire Dawa, and Harar) had higher odds of engaging in early initiation of breastfeeding, but had a lower likelihood of exclusive breastfeeding. This finding was supported by evidence from a systematic review conducted in Ethiopia, where mothers residing in urban areas had the highest proportion of early initiation of breastfeeding, but also the lowest prevalence of EBF compared to rural areas [16]. A possible explanation for the higher prevalence of early initiation of breastfeeding in urban mothers may be that mothers residing in urban areas may have higher educational levels, with potential improved access to breastfeeding information [38]. Nevertheless, there is a disparity in the literature on the influence of place of residence on early initiation of breastfeeding worldwide. For instance, mothers who live in rural Nigeria [30], Sri Lanka [45] and India [40] were more likely to delay breastfeeding initiation compared to those who live in urban Nigeria, Sri Lanka and India. However, mothers residing in rural Bangladesh were more likely to initiate breastfeeding post-birth compared to their counterparts in urban Bangladesh [46]. A possible explanation for the decreased likelihood of EBF might be that metropolitan regions probably have a higher number of formally employed women [41].

In many LMIC countries (including Ethiopia), early initiation of breastfeeding is influenced by father’s education and household wealth [23, 28, 47]. The present study suggested that father’s education and household wealth were associated with initiation of breastfeeding within the first hour of birth, consistent with studies from Nigeria, Nepal, and Australia [30, 48, 49]. Educated fathers are more likely to be formally employed, with subsequent impact on the household wealth and productivity [50, 51]. This can also translate to increase breastfeeding awareness that might influence the mother to engage in optimal breastfeeding because partners plays a role an important role in a mother’s decision to initiate and continue optimal breastfeeding [52, 53]. The relationship between household wealth and early initiation of breastfeeding was demonstrated by a recent evidence from Nigeria, which suggested that 25.0% of non-EBF were attributable to lower household wealth [54]. In Ethiopia, health practitioners and policy-decision makers would do well to involve partners in breastfeeding promotion and support programs to maximize gains of breastfeeding interventions. In addition, improving human capital resources, particularly among women, in line with the current SDG-1.1 of eradicate extreme poverty and (SDG-4.3) of ensuring access to education for all women would be central to increasing breastfeeding outcomes in Ethiopia [13].

Research from nine sub-Saharan African countries indicated that frequent ANC visits was associated with early initiation of breastfeeding [55], possibly reflecting the impact of ANC services, including promotion of breastfeeding message by health professionals [55]. However, our study suggested that mothers who had frequent (≥ 4) ANC visits were more likely to delay breastfeeding initiation within the first hour of birth. This finding is consistent with research from Namibia, where frequent ANC visits were associated with delayed breastfeeding initiation post-birth [38]. A plausible reason for this finding may be that health practitioners have limited knowledge about optimal infant feeding [56] or an absolute lack of accredited Baby-Friendly Hospital Initiative (BFHI) facilities in Ethiopia [57]. This indicates that while many mothers may have received routine ANC information, they may have had limited opportunities to obtain appropriate breastfeeding information. Additionally, the association between frequent ANC visits and delayed initiation of breastfeeding may also be due to problematic pregnancies or ill health experienced by mothers, which may require frequent health service visits. Nonetheless, initiating and implementing the BFHI strategy would be crucial in assisting efforts to implement breastfeeding practices that protect, promote and support appropriate breastfeeding in Ethiopia.

Our study indicated that health facility birthing was associated with early initiation of breastfeeding, and this was in line with a systematic review from Ethiopia [58] and studies from Nigeria [28], Namibia [38], and Uganda [59]. The practice of EBF in the early postnatal period is affected by many factors, even when there is delay in breastfeeding initiation. These factors include cesarean birthing [20, 30, 52], cultural practices [37, 60], and influence of grandmothers [61]. Importantly, a woman’s engagement with the health facility in the perinatal period remains a major determining factor in ensuring optimal infant feeding behavior. This health facility engagement does not only provide relevant and appropriate information to the woman but also gives the woman confidence and information to challenge perceived cultural practices, myths and belief system held towards breastfeeding in the community [62]. In Ethiopia, interventions to increase the pace of progress for EBF should involve the health facilities, including training of health practitioners, accrediting health facilities for BFHI, and evaluating the quality of health services provided.

Young mothers, female children, and mothers who desired the pregnancy were associated with higher odds of early initiation of breastfeeding. Mothers who were in the age group of 25–34 years had significantly higher odds of early initiation of breastfeeding which might be explained that they are in the peak of reproductive age group to start a family. A study conducted in Bangladesh showed that teenage motherhood was associated with delayed initiation of breastfeeding In the current study, female infants had a higher odds of early initiation of breastfeeding compared with male children which is similar to a study conducted in regional Ethiopia [63]. The relationship between a woman’s desire for pregnancy and early initiation of breastfeeding was supported by a similar study conducted in Turkey, which reported that unwanted pregnancy decreases the odds of early initiation of breastfeeding [64]. This finding could be explained by the compromised attitude of the mother towards the baby, which may affect her intention to initiate breastfeeding, as well as her decision for optimal baby care in general [64]. Additionally, well conducted qualitative studies may be needed to understand the reasons for why EBF prevalence has not substantially increased in Ethiopia to inform focused interventions.

The present study showed that early initiation of breastfeeding improved in Ethiopia during the MDG era but it is still below the national target; while the progress in EBF remained slow. Improving breastfeeding practices of Ethiopian mothers and ensuring that national breastfeeding targets are met would require targeted efforts at the individual, health facility and community levels. It is also important that national and subnational policy-makers and nutrition expert in Ethiopia consider successful intervention strategies from evidence-based studies when designing breastfeeding programs.