Exclusive breast feeding (EBF) is an important public health strategy for reducing infant and child morbidity and mortality as well as reducing maternal morbidity and mortality. It is defined as an infant’s consumption of human milk with no type of supplementation, even if water, except for vitamins, minerals, and medications until six months. Exclusive breastfeeding for six months is protective effect against gastro-intestinal infections, which is observed not only in developing but also in industrialized countries [1].

World Health Organization (WHO) and United Nations Children’s Fund (UNICEF) recommend that all mothers should breastfed their children exclusively for first six months and thereafter continue as long as mother and child wish, and both appropriate and sufficient weaning food should be added after six months of life [2-4].

EBF practice was highly affected by cultural malpractice, attitude and knowledge of mothers and or caregivers [5]. As age of child increase rate of EBF decreased as evidence done in Nepal, Nigeria, Uganda and Ethiopia [6, 7]. Poor practices and attitudes toward exclusive breastfeeding have been reported to be among the major reasons for poor health outcomes among children, particularly in developing countries. The six causes of 90% of under-five child mortality worldwide - acute respiratory infections, diarrhea, measles, malaria, HIV and AIDS and neonatal conditions - are easily preventable [8]. The highest levels of under-five mortality continue to be found in Sub-Saharan Africa, where one in eight children die before the age of five (129 deaths per 1,000 live births) - nearly twice the average in developing regions overall and around 18 times the average in developed regions [9]. Diarrhea, malaria and pneumonia are responsible for more than half the deaths of children under five in Sub-Saharan Africa [8].

The 2016 Ethiopian DHS shows, overall, 58% of children under age 6 months are exclusively breastfed, and the percentage of exclusive breastfeeding declines with age from 74% in 0-1 months to 36% in 4-5months. Contrary to the recommendation that children under the age of 6 months be exclusively breastfed, many infants are also fed with other liquids such as water (17%), non-milk liquids (5%), and other milks (5%) before reaching age 6 months (0-5 months). Moreover, 11% of infants begin complementary foods before 6 months of age, with more than one-fifth of children (21%) consuming complementary foods by age 4-5 months [10].

Breastfeeding is a cost effective intervention that could save so many new born lives. This disadvantageous for developing country mothers cannot afford to purchase breast- milk substitutes and they provide it to the infant with the necessary hygiene and frequency. For many poor households the high cost of breast- milk substitute and equipment represents a substantial drain on scarce household resources [11-13]. Therefore, this study was designed to fill gap of practice due to associated factors of Exclusive Breast Feeding among lactating mothers particularly at study area.

Study setting/Area

Community based cross sectional was conducted in Gedeo Zone Dilla Zuria destrict selected kebeles from May to June 2019. It is bordered by Guji Zone in Southwest and in South, Dilla town and latitude 6°24′30″N 38°18′30″E/ 6.40833°N 38.30833°E, with an elevation of 1570 meters above sea level. The total population of Kebeles are 11583, of this 5699 are males and the rest 5884 are females. Among; this 492 lactating mothers which was less than one year children and it has one (1) health care center & four (4) health posts.

Sample size and sampling procedure

The sample size for study was determined using a single population proportion formula considering the similar study conducted in Jimm Zone proportion value 49% [16] at a 95% CI and a 5% margin of error (d). Finally 237 sample size was obtained after adding 10% non-response rate. Simple sampling technique was employed to draw women who lived in study area those had child less than one year olds those addressed through survey before determination of sample size. Then at the end the total sample size of participants was selected lottery method based on their house numbers.

Study variables and population

The outcome variable of this study was practice status and its application tested by yes or no. The factors used to determine associations with practice of EBF were some of the selected socio-demographic characteristics and knowledge& attitude of the study participant. As a result the study focused on all the mothers had less than one year children, who were available during the study period at the place of door to door and a few women who were unable to communicate effectively by giving requested information and critically ill including hearing and speaking health problem during the data collection period were excluded from being studied.

Data collection tools and procedure

A structured interviewer-administered questionnaire was used to collect data through face to face interview. The questionnaire was constructed in two major sections, socio-demographic and knowledge, attitude& practice parts. The outcome variable was categorized as poor or good practices.  A total of five data collectors (four community health workers) and one supervisor (health officer) engaged and contributed in the study and two days of training was given to data collectors and supervisor.

To ensure consistency, the English version of the questionnaire was translated into local language Gedeoffa and then back translated to English language version by other expert of the first one. The data collection tool was pretested on 5% of the study subjects out of the selected kebele to get the reliable and necessary information according to the aim of the study, since it was developed from related studies and modified to context of current study.

Statistical analysis

The collected data was entered, cleaned and analyzed using Statistical Package for Social Sciences (SPSS) version 20.Descriptive statistics, including frequencies and proportions were used to summarize variables and displayed by tables and graphs. A bivariable analysis was carried out to see the crude effect of each independent variable on practice of exclusive breast feeding. Variables with a P-values of <0.25 were candidate to enter into the multivariable logistic regression analysis. Both Crude Odds Ratio (COR) and Adjusted Odds Ratio (AOR) with a corresponding 95 % Confidence Interval (CI) were computed to show the strength of the association. In the adjusted analysis; at P-value showed less than 0.05 was used to state statistical significance.

A total of 237 mothers having of child below one years of age were involved in the study; at the response rate of 100%. The age of the respondents was between 25-34 ages of years 95(40.2%) was high frequency of the rest. Over three-fourth of the respondents are married 189(79.7%) and about 132(55.7%) of them were housewives. Two-third of study participants have heard about EBF 157( 66.2%) for the first 6 months and their main source of information were health institution 77(32.5%)and  followed by during ANC follow up  61(25.7%) and majority of the participant was good knowledge 196(82.7%). Over half 142(59.9%) of mothers had positive attitude on duration of EBF for 6 months and about 148(62.4%) of mothers agree on the early initiation of breast feeding.

Table 1: Socio demographic characteristic and knowledge& attitude of mothers who have infant less than one years in Dilla zuria District Gedeo Zone 2019. Physical Sparing Reconstruction

Practice of Exclusive breast feeding among respondents

In this study greater than half of the mothers was practicing exclusive breast feeding their child139 (58.6%). Among the participants about 99(41.8%) had practice of pre lacteal feeding and out of them 120(50.6%) gave cow milk and 22(32.5%) gave butter. The reason for giving pre lacteal feeding was inadequate breast milk 140(59.1%), maternal illness 8(18.2%), breast problem 18(18.2%) and other 4(9.1%). On the other hands 88 (37.1%) mothers were breast feeding <8 times per day and 84(35.4%) 8-10 times per a day.

Associated factors with exclusive breast feeding

In the bi-variable logistic regression analysis, educational status, occupational status of husband, , knowledge on source of information and attitude of EBF is possible up to six months were factors associated with  practice of exclusive breast feeding at a p-value of less than 0.25.Consequently, these variables  were subjected to multivariate analysis and it was indicated that occupational status of husband, educational status of mothers and attitude of EBF is possible up to six months were significantly associated with good practice of exclusive breast feeding at a p-value of less than 0.05 with 95% CI. The odd of practice of EBF among mothers who had positive attitude 14.508 times [AOR= 14.508; 95%CI: 1.576-33.566] higher than that of mothers who had negative attitude toward practice of EBF.

This study was try to address practice of EBF and its determinants among mothers with children less than 1 years of age. Among the participants the majority 196(82.7.%) of the mothers had good knowledge which had less than the result  with a study done in Badele, Ethiopia majority of mothers (91.8%) knew the importance of EBF[14] and a study done in Ambo, Ethiopia ,90.8% of mothers were knowledgeable about EBF[15]. The discrepancy may be the opportunity of exposure to information different from place to place. The study done in Jimma, in 2013 showed about 53.7% of mothers were knowledgeable which is lower than the current study [16]. This difference might be due to the difference in study period and that currently majority of the study participants could get access to health information about EBF through mass media & health workers.

Greater than half 133(56.1%) of mothers in this study had positive attitude towards EBF for the first 6 months which was less than with study that was done in Jimma town, 2013, about 73.9% of mothers had positive attitude towards EBF[16]. The reason was due to difference in geographical areas and life style including socio-culture of the community. Concerning the practice of EBF in this study, 139(58.6%) of them practiced EBF up to 6 months which was nearly equal with a study done in Arbaminch, Ethiopia that 55.6% of mothers were exclusively breastfed their children for 6months [17], lower than study done in Debre berhan 68.6%(42) and because of a difference of study site and less accessibility to source of information of current study area [18].

Half of the participant practice 119(50.2%) of study participants initiated breast feeding within one hour while 133(56.1%) had positive attitude toward early initiation of breast feeding. But according to EDHS 2016 73% children began breast feed within 1 hour of birth and 92 %within 1 day of birth [10]. In this study might be due to that majority of mothers delivered their child at health institutions so; that they had a chance to start breast feeding immediately after birth. On the other hand mother who had positive attitude EBF up to six month more practice than who had negative attitude toward practice of EBF.

This study showed that educational status of mother benign illiterate 1.51 times more affects practice of EBF than other education status of respondents [ARO=1.51; 95%CI: 1.414-4.198]. This applies that more educated might be initiation good practice of EBF up to six month of child birth and in lined with study conducted in Debra Berhan District, Harar and North Gondar Zone [18-20]. Likewise; the occupation of the husband being farmer 3.074 times more affects practice of EBF than others occupations of other respondents [AOR= 3.074; 95%CI: 1.602-9.430]. This may be the load of seasonal tasks related cultivating and harvesting products enforce to leave a child at home and occupied with work.

Table 2: Factors associated with practice of exclusive breast feeding among lactating mothers in, Dilla zuria District, Gedeo Zone 2019.

Note: +P<0.25, *P<0.05, **P<0.01& ***P<0.001

Practice of exclusive breast feeding of this study was relatively less compared to related studies and level of education, occupation of husband and positive attitude were investigated factors.  So, attention in health planning should be given on exclusive breast feeding promotion; health care providers and decision makers should be comprehensively address issues to improve more exclusive breast feeding practice in the community is recommended.

AOR: Adjusted odd ratio; COR: Crude odd ratio; EBF: Exclusive breast feeding; ANC: Antenatal Care; EDHS: Ethiopian Demographic Health Service.

We declare that we have no competing interests

GW contributed significantly in initiation and design of the study, data analysis and interpretation, drafting and critically revising the manuscript for important intellectual content. BN contributed design of the study, data collection, analysis and interpretation as well as drafting and revising the manuscript. Both authors have read and approved the final manuscript for possible publication.

The authors are very grateful to School of Public Health Dilla University, for approval of ethical clearance and material support. The authors are also grateful to all study participants.

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