Microsoft Word - Mihret.docx New articles in this journal are licensed under a Creative Commons Attribution 4.0 United States License. This journal is published by the University Library System of the University of Pittsburgh as part of its D-Scribe Digital Publishing Program and is cosponsored by the University of Pittsburgh Press. Sociodemographic Factors Associated with Bottle Feeding Practices in Infants Under Two Years of Age: A hospital-based study in Woldia, Ethiopia Yalew Mihret1, Fentanesh Endalew1, Hunegnaw Almaw2, Melese Linger3* 1Department of Midwifery, College of Health Science, Woldia University, Woldia, Ethiopia; 2Department of Public Health Nutrition, College of Medicine and Health Science, Bahir Dar University, Bahir Dar, Ethiopia; 3Department of Public Health, College of Health Science, Woldia University, Woldia, Ethiopia *Corresponding Author email: melselinger@gmail.com Vol. 9, No. 1 (2020) | ISSN 2166-7403 (online) DOI 10.5195/cajgh.2020.440 | http://cajgh.pitt.edu MIHRET This work is licensed under a Creative Commons Attribution 4.0 United States License. This journal is published by the University Library System of the University of Pittsburgh as part of its D-Scribe Digital Publishing Program and is cosponsored by the University of Pittsburgh Press. Central Asian Journal of Global Health Volume 9, No. 1 (2020) | ISSN 2166-7403 (online) | DOI 10.5195/cajgh.2020.440 | http://cajgh.pitt.edu Abstract Introduction: Bottle feeding should be avoided when possible in infants under the age of two to improve health outcomes. The magnitude of bottle feeding practice is currently increasing in Ethiopia, however factors associated with bottle feeding usage are rarely addressed in research. We aimed to fill this gap and assess the magnitude of bottle feeding and its association with sociodemographic factors among infants in Woldia, Ethiopia in 2019. Methods: A hospital-based cross-sectional study was conducted in Woldia General Hospital at the Immunization Clinic. A total of 255 mothers who had infants were selected by systematic random sampling method. Data was collected through face-to-face interview using a structured standardized questionnaire. The data was entered to EpiData version 3.1 and analyzed using SPSS version 20. Binary logistic regression analysis models were used to assess the association between dependent and independent variables. Variables with p-value < 0.2 in bivariable logistic regression analysis were entered to multivariable logistic regression analysis. Finally, variables with p-value < 0.05 with 95% CI in multivariable logistic regression were taken as independent predictors. COR and AOR were used to show the strength of association between the dependent and independent variables. Results: The rate of bottle feeding practice in this study was 42.7% (95%CI: 35.8,48.2). Being an infant age 0-5 months old [AOR=0.16; 95%CI: 0.06,0.4], being a mother age 35-50 years old [AOR=0.43; 95%CI: 0.22, 0.85], having 2-5 children [AOR=6.37; 95%CI: 1.33, 30.44], and being a farmer as reported mother’s occupation [AOR=2.72; 95%CI: 1.30, 5.67] showed significant association with bottle feeding practice. Conclusion: The magnitude of bottle feeding practice was significantly higher in the current study as compared to national prevalence. Several sociodemographic factors showed significant association with bottle feeding practice which need to be explored further in the future research. Keywords: Bottle feeding; Children; Sociodemographic factors Sociodemographic Factors Associated with Bottle Feeding Practices in Infants Under Two Years of Age: A hospital- based study in Woldia, Ethiopia Yalew Mihret1, Fentanesh Endalew1, Hunegnaw Almaw2, Melese Linger3* 1Department of Midwifery, College of Health Science, Woldia University, Woldia, Ethiopia; 2Department of Public Health Nutrition, College of Medicine and Health Science, Bahir Dar University, Bahir Dar, Ethiopia; 3Department of Public Health, College of Health Science, Woldia University, Woldia, Ethiopia *Corresponding Author email: melselinger@gmail.com Research Bottle feeding is the practice of feeding an infant any substitute for breast milk with a bottle. Based on World Health Organization (WHO) classification, a prevalence of exclusive breastfeeding below 50% is considered poor.1 The WHO recommends that 95% of infants younger than one month and 90% of those younger than six months should be exclusively breastfed, while 90% of those aged 6–23 months should be partly breastfed. However, in low and middle-income countries, only 37% of infants younger than six months of age are exclusively breastfed.2 In Ethiopia, about 77% of infants scored low or medium on the breastfeeding performance index during the first six months of life,3 and only 58% of infants under age six months are exclusively breastfed.4 CENTRAL ASIAN JOURNAL OF GLOBAL HEALTH This work is licensed under a Creative Commons Attribution 4.0 United States License. This journal is published by the University Library System of the University of Pittsburgh as part of its D-Scribe Digital Publishing Program and is cosponsored by the University of Pittsburgh Press. Central Asian Journal of Global Health Volume 9, No. 1 (2020) | ISSN 2166-7403 (online) | DOI 10.5195/cajgh.2020.440 | http://cajgh.pitt.edu The period between birth up to two years of the child’s life is a “critical window period” because during this period, infants are vulnerable to malnutrition or any other illness.5 Feeding exclusively breast milk within the first six months is considered a first vaccine for the infant.6 Despite breastfeeding recommendations, the prevalence and duration of breastfeeding is declining rapidly and is being replaced by bottle feeding, particularly among urban residents in developing countries.7 Bottle feeding is generally not recommended as it can lead to an increased incidence of excessive weight gain, diarrhea, infection, malnutrition, increased mortality, iron depletion, and decreased birth spacing.8-15 Even the expressed breast milk could increase infant weight gain if it is fed by the bottle.16 Globally, 45%, or 3.1 million, of child deaths are attributable to undernutrition annually; this problem is severe in low income countries.14 Increasing appropriate complementary feeding has the potential to prevent 6% of all under-5 deaths, particularly in the developing countries.5 Numerous studies in various countries have shown that being an urban resident,17,18 not being counseled on bottle feeding education,18,19 the infant being hospitalized,18 low infant age,19 being a homemaker, not obtaining postnatal care, lower mother’s age,19 being an employed mother, hospital delivery, high infant age,9,17 higher maternal education level, high wealth index,17,20,21 as well as workload and short maternity leave20,21 were contributing factors for bottle feeding. Previous research inconsistently reported factors associated with bottle feeding practice, especially sociodemographic variables, infant age, and mothers’ educational and occupational status. The government of Ethiopia adopted infant and young child feeding guidelines in 200422 and the national nutrition program in 201323 to unlock the lifesaving potential of optimal breastfeeding practices. The guideline is based on WHO recommendations that emphasizes exclusive breastfeeding. Furthermore, the health extension program in Ethiopia aims at improving proper infant and young child nutrition, including promotion of exclusive breastfeeding. 22 Although the government put forth the efforts mentioned above, the prevalence of bottle feeding practice among infants under two years was 11.9 %24 in 2011 and increased to 14% in 2016,25 according to Ethiopia Demographic and Health Survey Report. Therefore, this study was aimed to assess factors associated with bottle feeding practices among mothers with infants in Woldia General Hospital, Ethiopia, 2019. Methods Study setting and population This hospital-based cross-sectional study was conducted among mothers with infants (children less than 24 months of age) who attended the immunization clinic in Woldia General Hospital, Woldia, Ethiopia. The town is located 521 kilometers away from Addis Ababa, the capital city of Ethiopia, and 360 kilometers away from Bahir Dar, the regional city of Amhara. According to the national census of 2008, the town of Woldia had a total population of 75,496, of whom 38,167 were men, and 37,279 were women. Woldia has one general hospital and two health centers. This study was conducted from February to April 2019 at Woldia General Hospital. Sample size and sampling technique The sample size was calculated using a single population proportion formula: n=(Za/2)2P(1-P)/w2 with the assumptions Za/2=1.96 (95% confidence level), P=0.196 (19.6% as the prevalence of bottle feeding practice in Holeta town19) and w=0.05 (5% margin of error). The estimated sample size was 243. We accounted for a non-response rate of 10%, so our final sample size estimate increased to 267. A systematic random sampling technique was conducted to select a representative population in the immunization clinic. The sampling interval (K) was MIHRET This work is licensed under a Creative Commons Attribution 4.0 United States License. This journal is published by the University Library System of the University of Pittsburgh as part of its D-Scribe Digital Publishing Program and is cosponsored by the University of Pittsburgh Press. Central Asian Journal of Global Health Volume 9, No. 1 (2020) | ISSN 2166-7403 (online) | DOI 10.5195/cajgh.2020.440|http://cajgh.pitt.edu established by dividing the average number of women who visited the immunization clinic in the previous three months before data collection (average n=900) by the sample size, which produced K=900/267=3. Women were recruited daily by simple random sampling technique using the lottery method, and the next respondent was selected by adding a sampling interval to the number of the selected women. The same procedure was done on subsequent days until the required sample size was reached. Exposure and outcome variables The exposure variables were sociodemographic factors and obstetric factors. The definition and measurements standards of the variables were adopted from the Ethiopian Demographic and Health Survey 2016.25 The outcome variable was bottle feeding practice, which was categorized as yes/no. Bottle feeding practice was measured based on WHO definition of this indicator: "proportion of children 0–23 months of age that were fed any liquid (including breastmilk) or semisolid from a bottle with nipple/teat in previous 24 hours prior to data collection period".25 Data collection tools and procedures Data were collected by using a structured standard questionnaire through face-to-face interview. The questionnaire was adopted from the Ethiopian Demographic and Health Survey 2016.25 It has two parts: sociodemographic information and obstetric information. First, the English version of the questionnaire was prepared. It was translated to the local language of Amharic and then translated back to English. The data collectors were five graduate class midwifery students who had received one day of training before starting the data collection. The quality of the data collection process was monitored, and clear uniform instructions were given to all data collectors. All data collected as a part of this research were checked by the principal investigator. Data processing and analysis Data were entered and cleaned in EpiData version 3.1, and SPSS version 20.0 was used for data analysis. Descriptive statistical analyses were employed. Binary logistic regression analysis models were used to assess the association between dependent and independent variables. Variables with p-value of < 0.2 in bivariable logistic regression analysis were entered to multivariable logistic regression analysis. Finally, variables with p-value < 0.05 with 95% CI in multivariable logistic regression were taken as independent predictors for bottle feeding practice. COR and AOR were used to show the strength of association between the dependent and independent variables Ethical consideration Ethical clearance was obtained from the ethical review committee from the College of Health Science, Woldia University. The purpose of the study was explained, and confidentiality was secured by omitting any identifiers. Verbal consent was obtained from each study participant over 18 years of age. For mothers under 18 years of age, verbal consent was obtained from both, the participant and her guardian. Results Sociodemographic characteristics From the estimated sample size, 255 participants responded to survey, (95.5% response rate). Among the study participants, 222 (87.1%) were married, 155 (60.8%) were 15-24 years of age, 138 (54.1%) were orthodox by religion, and 165 (64.7%) of mothers were urban residents (Table 1). Obstetric related factors In this study, 241 (94.5%) mothers had antenatal care in their previous pregnancy. During their antenatal care follow up, 209 (87.1%) of women did not receive counseling about bottle feeding practice. From the total CENTRAL ASIAN JOURNAL OF GLOBAL HEALTH This work is licensed under a Creative Commons Attribution 4.0 United States License. This journal is published by the University Library System of the University of Pittsburgh as part of its D-Scribe Digital Publishing Program and is cosponsored by the University of Pittsburgh Press. Central Asian Journal of Global Health Volume 9, No. 1 (2020) | ISSN 2166-7403 (online) | DOI 10.5195/cajgh.2020.440 | http://cajgh.pitt.edu study participants, 218 (85.5%) received postnatal health care services for the current child (Table 2). Child feeding practices The overall rate of bottle feeding was 42.7% (95%CI: 35.8, 48.2) and the magnitude was 12.7%, 46.6% and 55.7% respectively when disaggregated into age categories of 0-5 months, 6-11 months and 12-24 months, respectively. Among the respondents who were asked about the reason why they practiced bottle feeding, around 42 (38.5%) respondents reported that they practiced bottle feeding due to work. Seventy (44.9%) anticipated practicing bottle feeding up to two years, and 176 (69.0%) previously obtained information on the benefits of breastfeeding from health professional (Table 3). Health status of an infant Among respondents who used bottles for feeding, 103 (58.9%) used formula, 18 (10.3%) of the mothers cleaned the bottle once daily, 39 (15.3%) of the infants had history of recurrent diarrhea in the past one month, and only 90 (51.4%) of the mothers cleaned the bottle through boiling (Table 4). Factors associated with bottle feeding practice In multivariable logistic regression analysis, infants aged 0-5 months old, mothers aged 35-50 years old, having 2-5 children and being a farmer as mother’s occupation showed significant association with bottle feeding practice. Other factors like father’s occupation, father’s education, antenatal care follow up, postnatal follow up, place of delivery, mother’s education level, sex of the child, parity and gravidity had no association with infant bottle feeding practices. Infants 0-5 months old were 84% less likely to be bottle fed than infants 12-23 months old [AOR=0.16; 95%CI: 0.06, 0.4]. Furthermore, mothers who were between 35-50 years old were 57% less likely to practice bottle feeding than those who were in between ages 15- 24 [AOR=0.43; 95%CI: 0.22, 0.85]. Mothers who had 2- 5 children were six times as likely to practice bottle feeding as compared to mothers who have 6-10 children [AOR=6.37; 95%CI: 1.33, 30.44]. Being a farmer as mother’s occupation increased the odds of bottle feeding by 2.7 times as compared to a mother who were homemakers [AOR=2.7; 95%CI: 1.30, 5.67] (Table 5). Variables Frequency Percentage Age of mother 15-24 40 15.7% 25-34 155 60.8% 35+ 60 23.5% Residence Urban 165 64.7% Rural 90 35.3% Marital status Married 222 87.1% Divorced 18 7.1% Single 8 3.1% Widowed 7 2.7% Mother’s occupation Homemaker 128 50.2% Farmer 32 12.5% Daily laborer 15 5.9 % Merchant 39 15.3 % Government employee 41 16.1% Educational status of mother Unable to read and write 64 25.1 % Primary 76 29.8% Secondary 68 26.7% Higher education 47 18.4% Religion of mother Orthodox 138 54% Muslim 91 36.2 Protestant 20 7.8% Others 6 2% Occupation of husband Farmer 72 28.2% Daily laborer 21 8.2% Merchant 86 33.7% Government employee 76 29.8% Educational status of husband Illiterate 38 14.9% Primary 73 28.6% Secondary 60 23.5% Higher education 84 32.9% Note: Other religions=Adventist Table 1. Sociodemographic characteristics of mothers with infants less than 24 months of age in Woldia General Hospital, Ethiopia, 2019 (N=255) MIHRET This work is licensed under a Creative Commons Attribution 4.0 United States License. This journal is published by the University Library System of the University of Pittsburgh as part of its D-Scribe Digital Publishing Program and is cosponsored by the University of Pittsburgh Press. Central Asian Journal of Global Health Volume 9, No. 1 (2020) | ISSN 2166-7403 (online) | DOI 10.5195/cajgh.2020.440 | http://cajgh.pitt.edu Variables Frequency Percent Gravidity of mother Primigravida 70 27.5% Multigravida 185 72.5% Number of children 1 75 29.4% 2-5 160 62.7% 6-10 20 7.8% Age of youngest child in months 0-5 55 21.6% 6-11 103 40.4% 12-23 97 38% Sex of infant Male 163 63.9% Female 92 36.1% Attended PNC for the current child Yes 218 85.5% No 37 14.5% Attended ANC for the last pregnancy Yes 241 94.5% No 14 5.5% Counseling about bottle feeding obtained No 209 87.1% Yes 31 12.9% Place of delivery Health institution 179 70.2% Home 76 29.8% Note: PNC=Postnatal care, ANC=Antenatal care Table 2. Obstetric related factors of mothers with infants less than 24 months of age in Woldia General Hospital, Ethiopia, 2019 (N=255) MIHRET This work is licensed under a Creative Commons Attribution 4.0 United States License. This journal is published by the University Library System of the University of Pittsburgh as part of its D-Scribe Digital Publishing Program and is cosponsored by the University of Pittsburgh Press. Central Asian Journal of Global Health Volume 9, No. 1 (2020) | ISSN 2166-7403 (online) | DOI 10.5195/cajgh.2020.440 | http://cajgh.pitt.edu Variables Frequency Percent Source of information on the advantage of breast feeding Mass media 28 11% Health professional 176 69% Family 51 20% Type of feeding for the youngest children now Only breast milk 100 39.2 Only bottle feeding 32 12.5 Breast and other foods with cup and spoon 116 45.5% Other food with cup and spoon 7 2.7% Duration of bottle feeding practice Up to 6 months 30 19.2% Up to 1 year 37 23.7% Up to 2 year 70 44.9% Until the baby discontinues 19 12.2% Child bottle fed presently Yes 109 42.7% No 146 57.3% Reasons to start bottle feeding Mothers return to work 42 38.5% Inadequate breast milk 30 27.5% Availability of formula milk 14 12.8% Pregnancy 3 2.8% Mother is ill 20 18.3% Time of initiation of breast feeding Immediately after birth 218 85.5% After 1 year 23 9% When the mother feels comfortable 10 3.9% I don’t know 4 1.6% Breast feedings per day 1-7 107 42% ≥ 8 148 58% Table 3. Child feeding practices among mothers with infants less than 24 months of age in Woldia General Hospital, Ethiopia, 2019 (N=255) MIHRET This work is licensed under a Creative Commons Attribution 4.0 United States License. This journal is published by the University Library System of the University of Pittsburgh as part of its D-Scribe Digital Publishing Program and is cosponsored by the University of Pittsburgh Press. Central Asian Journal of Global Health Volume 9, No. 1 (2020) | ISSN 2166-7403 (online) | DOI 10.5195/cajgh.2020.440 | http://cajgh.pitt.edu Variables Frequency Percent Source of water for drinking Pipe 205 80.4% River 13 5.1% Spring (protected) 35 13.7% Other 2 0.8% History of recurrent diarrhea in the past one month Yes 39 15.3% No 216 84.7% History of illness in the past one month Yes 20 7.9% No 235 92.1% Type of illness Diarrhea 5 25% Weight loss 4 20% Vomiting 3 15% Abdominal pain 5 25% Respiratory infection 3 15% Number of bottles One 60 34.3% Two 73 41.7% More than two 42 24% Frequency of bottle cleaning Every feeding pattern 91 52% Only when spoiled 34 19.4% Once daily 18 10.3% Every 6 hours 32 18.3% Techniques of cleaning the bottle Boiling 90 51.4% Rinsing with water and soap 64 36.6% Only rinsing with water 21 12% Additional food with bottle feeding Yes 105 60% No 70 40% Kind of fluid offering to the baby with bottle feeding Cow’s milk 63 36% Formula milk 103 58.9% Tea 2 1.1% Expressed breast milk 7 4% Note: Other water source=unprotected spring Table 4. Health status of infants less than 24 months of age in Woldia General Hospital, Ethiopia, 2019 (N=255) CENTRAL ASIAN JOURNAL OF GLOBAL HEALTH This work is licensed under a Creative Commons Attribution 4.0 United States License. This journal is published by the University Library System of the University of Pittsburgh as part of its D-Scribe Digital Publishing Program and is cosponsored by the University of Pittsburgh Press. Central Asian Journal of Global Health Volume 9, No. 1 (2020) | ISSN 2166-7403 (online) | DOI 10.5195/cajgh.2020.440 | http://cajgh.pitt.edu Variable Bottle feeding COR (95% CI) AOR (95% CI) Yes No Mother’s age in years 15-24 18 22 1 1 25-34 74 81 0.89(0.446,1.800) 0.46(0.19,1.10) 35-50 17 43 2.07(0.896,4.787) 0.43(0.22,0.85) Child’s age in months 0-5 7 48 0.17(0.07,0.4) 0.16(0.06,0.4) 6-11 48 55 0.89(0.51,1.55) 0.96 (0.51,1.8) 12-24 54 43 1 1 Number of children 1 30 42 7.07 (1.53,32.66) 4.12(0.8,21.19) 2-5 70 86 7.7(1.73,34.48) 6.37(1.33,30.44) 6-10 9 18 1 1 Mother’s occupation Homemaker 48 80 1 1 Farmer 12 20 11(0.45,2.23) 2.72(1.3,5.67) Daily laborer 6 9 0.9(0.3,2.69) 2.29(0.87,6.04) Merchant 18 21 0.7(0.34,1.44) 2.75(0.79,9.24) Government employee 25 16 0.38(0.19,0.79) 1.79(0.72,4.42) Mother’s educational status Unable to read and write 20 44 0.36(0.19,0.69) 4.12(0.8,21.19) Primary 25 51 0.39(0.21,0.71) 0.27(0.64,1.01) Secondary and above 64 51 1 1 Note: P-value significant at level of P<0.05, Backward LR method, Hosmer Lemeshow P-value=0.98 Table 5. Multivariable logistic regression analyses among mothers with infants less than 24 months of age in Woldia General Hospital, Ethiopia, 2019 Discussion The aim of this study was to assess the magnitude of bottle feeding practice and associated factors among infants less than two years old in Woldia General Hospital. In the current study, the prevalence of bottle feeding practice was 42.7% (95%CI: 35.8, 48.2). Age of the child, age of the mother, mother's occupation, and number of children in the family were found to be associated with bottle feeding practice. The magnitude of bottle feeding in the current study was consistent with the studies conducted in Sudan and Namibia.17,18 The magnitude of bottle feeding in this study was higher compared to the national prevalence reported in the 2016 EDHS,25 Holeta town,19 Bahir Dar26 and Nigeria.27 The possible reason for this difference might be attributed to study period variation, as there has been increasing advocacy for using formula in this region recently. MIHRET This work is licensed under a Creative Commons Attribution 4.0 United States License. This journal is published by the University Library System of the University of Pittsburgh as part of its D-Scribe Digital Publishing Program and is cosponsored by the University of Pittsburgh Press. Central Asian Journal of Global Health Volume 9, No. 1 (2020) | ISSN 2166-7403 (online) | DOI 10.5195/cajgh.2020.440|http://cajgh.pitt.edu The practice of bottle feeding from the current findings was lower than in the study conducted in Ethiopia.21 There might also be differences due to variations in socio-cultural aspects among study participants regarding feeding practices. Mothers in the age group of 35-50 were less likely to practice bottle feeding as compared to mothers in the age range of 15-24 years old. This finding is also supported by another study conducted in Southern Nation Nationality of People Regional State, Ethiopia, 2016.28 The possible explanation could that as mothers age increases, her experiences in childcare increase as well, and more appropriate care and feeding patterns are adopted. Infants in the age group of 0-5 months old were less likely to be bottle fed than infants 12-23 months old; this finding has also been reported elsewhere19 and inconsistent in studies conducted in Namibia17 and Kenya.9 Infants, especially those less than 6 months of age, have gastrointestinal systems that are not well matured. Bottle feeding at this age may be associated with problems in digestion and absorption, which in turn may lead to diarrhea, vomiting, and infections. If mothers had experienced this previously, they may not start bottle feeding their child within the first year. Being a farmer as the mother’s occupation increased the likelihood of bottle feeding as compared to mothers who were homemakers. This result is consistent with a study conducted in Brazil, in which women who worked outside of home practiced bottle feeding more often.29 This pattern may be attributed to challenging workload among mothers who are working in farming. This study had some limitations. The cross- sectional nature of the study may be subject to recall bias, and social desirability bias might influence the determinants of bottle feeding. For future researchers, conducting the studies with large sample size and incorporating factors such as media exposure and social media utilization will help to identify other important predictors of bottle feeding practices. The study’s strength is that it used primary data and included infants up to the age of two, which helps to estimate the magnitude of bottle feeding appropriately. Designing special nutrition intervention program for mothers who are working in farming, as well as developing a strategy to increase mothers' education in the area of nutrition and infant health, could contribute to lower bottle feeding use and improved infant outcomes. References 1. Batista CLC, Ribeiro VS, Nascimento M, Rodrigues VP. Association between pacifier use and bottle-feeding and unfavorable behaviors during breastfeeding. 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