Timely Initiation of Breastfeeding and Its Associated Factors at the Public Health Facilities of Dire Dawa City, Eastern Ethiopia, 2021

Introduction Timely initiation of breastfeeding is defined as putting the newborn baby to the breast within one hour of birth. Despite the World Health Organization and national recommendations on timely initiation of breastfeeding, delayed initiation of breastfeeding is still a common problem. Objective The aim of this study was to assess the timely initiation of breastfeeding and its associated factors at the public health facilities of Dire Dawa city, Eastern Ethiopia, 2021. Methods A health facility-based cross-sectional study was employed from February 1, 2021, to March 2, 2021, at the public health facilities of Dire Dawa city among 302 mother-child pairs. The data were collected by systematic random sampling technique, entered into Epi data 4.2, and analyzed using Statistical Package of Social Science 25.0 version. Bivariate and multivariable logistic regression analyses were employed to estimate the crude and adjusted odds ratio with a confidence interval of 95%, and a P value of < 0.05 was considered statistically significant. Frequency tables, figures, and descriptive summaries were used to describe the study variables. Results In this study, timely initiation of breastfeeding was 70.9% (95% CI: 65.6-75.8%). In a multivariable analysis, maternal age group of 25-40 years (AOR = 2.21, 95% CI = 1.09 − 4.48), multiparty (AOR = 2.58, 95% CI = 1.24 − 5.40), counselling on timely initiation of breastfeeding during antenatal care visits (AOR = 2.38, 95% CI = 1.16 − 4.88), institutional delivery (AOR = 3.29, 95% CI = 1.27 − 8.52), vaginal delivery (AOR = 3.06, 95% CI = 1.20 − 7.81), counselling on breastfeeding immediately after delivery (AOR = 2.89, 95% CI = 1.29 − 6.45), not practicing pre lacteal feeding (AOR = 6.76, 95% CI = 2.35 − 19.44), and having good practice of colostrum feeding (AOR = 4.03, 95% CI = 1.95 − 8.36) were associated with timely initiation of breastfeeding. Conclusion and Recommendation. Mothers who had practiced timely initiation of breastfeeding were low compared to the national recommendation (92%). Age of the mother, multiparity, counseling on timely initiation of breastfeeding, institutional delivery, vaginal delivery, counseling after delivery, not practicing prelacteal feeding, and having a good practice of colostrum feeding were predictors of timely initiation of breastfeeding. It indicates a need to encourage mothers to have antenatal care visits and institutional delivery.


Background
The first hours and days after birth are one of the riskiest periods of a child's life, but getting an early start to breastfeeding offers a powerful line of defences [1]. Babies are born ready to breastfeed; however, breastfeeding was an endangered practice in both rich and poor countries [2]. Breast-feeding is an unequalled way of providing ideal food for the healthy growth and development of infants; it is also an integral part of the reproductive process with important implications for the health of mothers [2].
When breastfeeding is delayed after birth, the consequences can be life-threatening and the longer newborns are left waiting, the greater the risk. For newborns, every minute counts, waiting 2-23 hours increases their risk of death by 1.3 times, and waiting 1 day or more increases their risk of death by more than 2 times [1]. Globally, about 2.6 million neonates die each year, most of which occurred within the first 7 days after birth, with about 1 million dying on the first day and close to 1 million dying within the next 6 days [3]. Two-thirds of neonatal mortality occur in South-East Asia and Sub-Saharan Africa [4,5].
Based on the World Health Organization (WHO) report, globally over one million newborn infants could be saved each year by initiating breastfeeding within the first hour of life [6]. Timely initiation of breastfeeding (TIBF) is defined as putting the newborn baby to the breast within one hour of birth [1]. Studies reported that TIBF can reduce more than 20% of neonatal deaths [7]. The Baby-Friendly Hospital Initiative develops ten steps to successful breastfeeding and has been accepted as minimum global criteria for designation of a hospital as Baby-Friendly. TIBF is one of the ten steps of successful breastfeeding [8].
Timely initiation of breastfeeding is recognized as the first and vital step toward reducing mortality in infants and children under five years of age [9]. The WHO and the United Nations Children's Fund recommend that breastfeeding should be initiated within the first hour after birth, continued exclusively for the first 6 months of life, and continued, with safe and adequate complementary foods, up to 2 years or beyond [3,8].
An estimated about 78 million newborns had to wait more than one hour to be put to the breast and only 42% of newborns were put to the breast within the first hour of life, ranging 35% in the Middle East and North Africa to 65% in Eastern and Southern Africa [1]. Furthermore, no country had more than 80% of babies breastfeeding within an hour of birth [10]. In Ethiopia, according to EDHS 2016 report, the prevalence of TIBF was 73% [11].
Even though the WHO and the United Nations Children's Fund recommended initiating breastfeeding within the first hour of birth, still a large number of mothers practiced delayed initiation of breastfeeding [3,12]. In developing countries like Ethiopia, delayed initiation of breastfeeding, discarding colostrum, and the introduction of dirty and unsound artificial feeding of infants with very dilute milk products are common [2]. Consequently, these man-made problems affect directly and indirectly the health of newborn infants and cause malnutrition and increase the risk of infection and death among neonates [7,13,14].
The Sustainable Development Goals target (SDG), to reduce neonatal and under-five deaths to less than 12, and 25 per 1000 live births respectively through eliminating preventable child deaths by the year 2030 [15]. Knowing the practice of TIBF is important for the implementation of the SDG. Our study was conducted on mothers who gave birth of mature and healthy newborn, while preterm birth was excluded.

Study Design and Period.
A health facility-based crosssectional study design was employed from February 1, 2021, to March 2, 2021, at the public health facilities of Dire Dawa city.

Study Area.
The study was conducted in Dire Dawa city health facilities. It is located about 515 km away from the capital city of Ethiopia, Addis Ababa. The city has ten public health facilities (two hospitals and eight health centers). The city has a total population of 506,936, of these 248,298 are males and 258,638 are females. There were about 162,220 rural and 344,716 urban residents with an average household size of 4.5 and 2.5, respectively [16].
2.3. Source Population. The source population was mothers who were visiting the child immunization clinic at the public health facilities of Dire Dawa city.

Study Population.
The study population was all mothers who attended the child immunization clinic in selected public health facilities of Dire Dawa city during the study period.

Inclusion and Exclusion
Criteria. All mothers who had babies less than or equal to twelve months and attended the child immunization clinic at the selected public health facilities of Dire Dawa city were included, while mothers who gave preterm birth excluded.
2.6. Study Variables 2.6.1. Dependent Variable. Timely initiation of breastfeeding: the mother was asked whether she have ever breastfed, and then TIBF was assigned with a code of "1" if she started breastfeeding within one hour of delivery and "0" if she started breastfeeding after one hour of delivery) 2.6.2. Independent Variables. Sociodemographic factors: age, residency, marital status, religion, educational level, occupation, partner educational status, and with whom she was living Obstetrics factors: parity, ANC visit, counseling on TIBF, colostrum feeding and breastfeeding during ANC visits, place of delivery, birth attendant, mode of delivery, and counseling on breastfeeding immediately after delivery.
Knowledge and practice of colostrum and breastfeedingrelated factors 2.6.3. Operational Definitions. Timely initiation of breastfeeding: is defined as putting the neonate on the mother's breast to suckle breast milk (or colostrum) within one hour of birth as reported by the mother [17] Colostrum: it is the yellowish breast milk produced within the first few days after delivery [18] Practice: the behaviour, habit, or custom of mothers of infants on colostrum feeding of their current infants. Mothers were considered to have a good practice of colostrum feeding if she correctly answered ≥60% of the total practice assessing questions Knowledge: refers to the knowledge of mothers about colostrum and breastfeeding and includes the timing of initiation of breastfeeding and an awareness and understanding of the mothers about the advantage of colostrum feeding. It was evaluated by the mother's answer to the knowledge-2 BioMed Research International related questions. The mother was considered to have good knowledge if she correctly answered ≥60% of the total knowledge assessing questions [17] 2.6.4. Sample Size Determination. The sample size was calculated using a single population proportion formula by considering the following assumptions: the proportion of TIBF among mothers having children less than two years in Debre Tabor was 76.8% [19], Zα/2 = critical value for normal distribution at 95% confidence level, which is equal to 1.96 (Z value of alpha = 0:05) or 5% level of significance (α = 0:05) and a 5% margin of error (ω = 0:05).
The sample size was adjusted by adding a 10% nonresponse rate, and the final sample size was 302 motherchild pairs. 2.6.5. Sampling Procedure and Technique. The data were collected in the selected public health facility of Dire Dawa city. The total sample size was proportionally allocated for each health facility of the city based on their monthly expanded program of immunization unit flow. The average number of mothers who visited the expanded program of immunization unit per month based on the expanded program of immunization registration book at all selected health facilities was 1405. The numbers of mothers who visited the expanded program of immunization unit monthly were 570, 310, 251, and 274 in Dill Chora referral hospital, Genda kore health center, Gende Gerada health center, and Goro health center, respectively. The total sample size was proportionally allocated for each health facility, based on their population size, and by using the following formula; Sample in the health facility = total sample n ð Þ x population in the health facility Ni ð Þ total population of the facilities N ð Þ The total sample size after proportional allocation was 122, 67, 54, and 59 mothers, respectively, in Dill Chora referral hospital, Genda kore health center, Gende Gerada health center, and Goro health center. Eligible mothers in each facility were selected by using systematic random sampling techniques. The sampling interval or the K th units (1405/302 = 5) were obtained by dividing the numbers of mothers who visited the expanded program of immunization unit monthly by the sample size. The starting unit was selected by using the lottery method among the first K th units in each health facility.
2.6.6. Data Collection Tools and Procedures. A structured interviewer-administered questionnaire was used to collect the data which were adapted from relevant works of literature and modified to the local context. Questionnaires were first prepared in the English language, and then, it was translated into Amharic by an individual who has good ability of these languages and then retranslated back into English to check the consistency. The questionnaire consisted of sociodemographic characteristics, reproductive, knowledge, and practice of colostrum and breastfeeding-related questions. Knowledge and practice of breastfeeding questions were assessed by +1 for a correct answer and 0 for an incorrect answer. The score for each mother was summed and categorized. A pretested structured interviewer-administered questionnaire was used for data collection purposes. The data were collected by four BSc midwives and supervised by one public health officer.
2.6.7. Data Quality Control. Data were collected by trained data collectors, and pretesting of the instrument was done before the actual data collection. The questionnaire was pretested before the actual data collection period on 5% [13] mothers who attended a child immunization clinic in Sabian General Hospital, which is not selected in this study. Data collectors and the supervisors were trained for two days by the investigator. After necessary modifications and correction were done to standardize and ensure its reliability and validity, additional adjustments were made based on the results of the pretest. The completeness of the data was checked by data collectors during data collection, and daily supervision was done for data completeness by supervisors.
2.6.8. Data Processing, Analysis, and Interpretation. The data were entered into Epi data 4.2, edited and cleaned for inconsistencies, missing values, and outliers, and then exported to SPSS version 25.0 for analysis. During analysis, all explanatory variables which have a significant association in bivariate analysis with a P value < 0.20 were entered into a multivariable logistic regression model to get AOR, and those variables with 95% of CI and a P value of < 0.05 were considered as statistically significant with TIBF. The multicollinearity test was done using variance inflation factor, and there was collinearity between the place of delivery and birth attendant. But, after removing birth attendants, there was no collinearity exists between the independent variables. The model goodness of the test was checked by using Hosmer-Lemeshow goodness of the fit, and its P value was 0.176. Frequency tables, figures, and descriptive summaries were used to describe the study variables.

Sociodemographic Characteristics of the Mothers.
A total of 302 mothers participated in the study with a response rate of 100%. The mean age of the mothers was 24.86 years with (±SD = 4:62) ranging from 15 to -40 years. Of these, 138 (45.7%) were found in the age group of 20-25 years. About, 80% (n = 241) of the mothers lives in urban and 287 (95.0%) were married. Of the mothers, 157 (52.0%) were Muslim religious followers and 117 (38.7%) had primary educational levels. More than half (57.0%) were housewives and 260 (86.1%) lives with their partner (Table 1).

Obstetric Characteristics of the Mothers.
In this study, 222 (73.5%) of the mothers were multigravida and 245 (81.1%) had a history of ANC visit in their most recent pregnancy. Among mothers who had a history of ANC visits, 198 (80.8%) were counseled on TIBF, and 196 (80.0%) were counseled on EBF. Of the mothers, 258 (85.4%) gave childbirth at a health institution and 261 (86.4%) of the childbirth were attended by health care professionals. Nearly, 87% (n = 262) of the mothers had a history of vaginal delivery and 240 (79.5%) were counseled on breastfeeding immediately after delivery (Table 2).

Knowledge of the Mothers on Colostrum and
Breastfeeding. In this study, according to the predetermined criteria, 189 (62.6%) mothers had good knowledge of colos-trum and breastfeeding. About half, 152 (50.3%), of the mothers obtained their information on colostrum and breastfeeding from health care professionals. Of the mothers, 269 (89.1%) responded that colostrum is the mother's breast milk during the first three days of delivery and 296 (98.0%) knew that colostrum is yellow in color. About 71% (n = 215) of the mothers responded that breastfeeding should start within an hour after delivery, and 163 (54.0%) knew that colostrum is nutritious and hygienic. Of the mothers, 207 (68.5%) responded that the baby should feed colostrum and breast milk on demand day and night without provision of any prelacteal feeding (PLF), and 157 (52.0%) knew that colostrum is important for the growth and development of the baby. About 210 (69.5%) responded that the baby should feed breast milk even if the mother is sick, and 238 (78.8%) of the mothers responded that the baby should feed breast when he/she is sick (Table 3).
3.4. The Practice of Colostrum Feeding. Two-thirds of the mothers, 206 (68.2%), had good practice of colostrum feeding. Of the mothers, 268 (88.7%) gave colostrum to their index child immediately after birth. It may cause abdominal discomfort 9 (26.5%) and my breast has no milk 9 (26.5%) were their main reason for not feeding colostrum    (Figure 1).

Association between Timely Initiation of Breastfeeding and Prelacteal
Feeding. There was a significant association between TIBF and PLF at a P value < 0.001. Among mothers who practiced TIBF, 207 (81.18%) were not given PLF to their index child, while mothers who started breastfeeding after one hour of delivery 40 (85.11%) were given PLF to their index child (Figure 2).

Factors Associated with Timely Initiation of
Breastfeeding. In bivariate analysis, maternal age, residency, educational level of the mothers, parity, history of ANC visit, counseling on; TIBF, and EBF during ANC visits, place of delivery, mode of delivery, counseling on breastfeeding immediately after delivery, not practicing PLF, good practice of colostrum feeding, and knowledge on colostrum and breastfeeding were significantly associated with TIBF at a P value of < 0.20. In a multivariable logistic regression analysis, maternal age, parity, counseling on TIBF during ANC visits, place of delivery, mode of delivery, counseling on breastfeeding immediately after delivery, not practicing PLF, and good practice of colostrum feeding remained significantly associated with TIBF at a P value of < 0.05.
Mothers who are found in the age group of 25-40 years were 2.21 times more likely to practice TIBF than mothers

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aforementioned studies might be due to the difference in the studies' sitting, as the majority of the above-mentioned study conducted in town sitting and the majority of mothers who lived in town sitting had formal education, while our study includes both urban and rural residency. There is supporting evidence from studies that shows that mothers who are lived in urban and had formal education were more likely to practice TIBF than their counterparts [32][33][34][35].

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The result in our study was also lower than studies conducted in Australia on women who were born in Turkey, Australia, and Vietnam and gave childbirth in Australia showing that the rate of TIBF was 8%, 84%, and 75%, respectively [36], Saudi Arabia (77.8%) [37], and south of Iran (96.0%) [38]. This discrepancy might be attributed to the difference in sociodemographic characteristics of the study participants and the implementation of health system.
In this study, sociodemographic and obstetrics characteristics and practice and knowledge level of mothers on colostrum and breastfeeding were significantly associated with TIBF. Mothers who are found in the age group of 25-40 were 2.21 times more likely to practice TIBF. The possible explanation might be mothers who are found in the age group of greater than or equal to 25 years may have more previous experience of breastfeeding as seen in this study more than three-fourth of women who are found in the age group of greater than or equal to 25 were multiparous. There is supporting evidence from studies conducted in different countries showing that being older-aged mothers were more likely to practice TIBF [37,53].
Multipara mothers were 2.58 times more likely to practice TIBF. This finding was in line with other studies [35,37,45,53]. The possible reason might be having previous experience of childbirth make multiparous mothers start breastfeeding earlier than primipara mothers. The other possible explanation might be multiparous mothers may have good skills and knowledge of newborn care and proper infant feeding practice. Mothers who are counseled on TIBF during their ANC visits were 2.38 times more likely to practice TIBF. This finding was supported by other studies conducted in Ethiopia [31,54]. The possible reason might be getting counseling about the advantage of early starting of breastfeeding may make them start breastfeeding timely, and this intern may increase their chance of practicing optimal breastfeeding.
Giving childbirth at the health institution increases the chance of TIBF by 3.29 times. This was consistent with other studies [25,28,45,47,53,[55][56][57]. The possible reason might be that giving childbirth at the health institution with the assistance of a health care provider may increase their chance of getting counseling about the advantage of TIBF compared to those who delivered at home with the assistance of a traditional birth attendant. The other possible explanation for this could be a difference in the health education provided by health professionals as part of labor and delivery care, and immediately after childbirth when compared with traditional birth attendants. There is supporting evidence from different studies conducted in Ethiopia showing that mothers who were attended by a traditional birth attendant/relatives during their last childbirth were less likely to practice TIBF [17,20,44].
Mothers who gave childbirth vaginally were 3.06 times more likely to initiate breastfeeding early. This was supported by studies conducted in Wolaita Sodo city [31], South Gonder zone [45], Gunchire town [25], Bahir Dar city [24], rural Eastern zone of Tigray region [43], and Motta town [28]. This was also consistent with studies conducted in Sub-Saharan Africa and India [52,53]. The 2016 EDHS secondary data analysis also shows that mothers who gave birth by cesarean section were 86% less likely to start breastfeeding early compared to mothers who had a vaginal delivery [55]. Mothers who gave birth by cesarean section were less likely to practice TIBF [33,44,58].
Counseling on breastfeeding immediately after delivery increased the chance of TIBF by 2.29 times. The possible reason might be being counseled after delivery may increase their chance of getting information about the advantage of TIBF over delayed initiation of breastfeeding. There is supporting evidence from studies conducted in Ethiopia [31,54]. Mothers who do not practice PLF were 6.76 times more likely to practice TIBF. This result was in line with another study [28]. The possible reason might be mothers who do not practice PLF may have good knowledge about breastfeeding. This was supported by studies conducted in Ethiopia showing that mothers who had good knowledge of breastfeeding were more likely to initiate breastfeeding timely [24,25].
Having a good practice of colostrum feeding increased the chance of TIBF by 4.03 times. The possible explanation might be mothers who had a poor practice of colostrum may take time to discard the first best and nutritious baby breast milk and this may delay the time of initiating breastfeeding. There is supporting evidence from a study conducted in Debre Berhan showing that not feeding colostrum was associated with delayed initiation of breastfeeding [44]. Delayed initiation of breastfeeding could be due to an attempt to discard colostrum, because milking or pumping out the colostrum may take more times even a day until it is removed from the breast and white milk starts to come out.

Limitation of the Study
Since this study included mothers whose index child age was up 12 months, recall bias might have occurred. To avoid this 9 BioMed Research International recall bias, we tried to remind them to remember the condition at the time of the delivery by asking questions like how was your feeling at the time of delivering and immediately after delivery, who was with you on that day, and when do you touch the body of your baby with your hands.

Conclusion and Recommendations
In our study, TIBF was comparable when compared to the 2016 EDHS report (73.0%), but it was lower when compared to the nationally recommended level of TIBF (92%). Among the predictors, age of the mother, counselled on TIBF during ANC visit, multiparty, institutional delivery, vaginal delivery, counseling on breastfeeding immediately after delivery, not practicing PLF, and having a good practice on colostrum and breastfeeding were significantly associated with TIBF. Even if in our study more than two-third of mothers practiced TIBF, still its gap is wide with WHO and national recommendation of breastfeeding. Therefore, massive awareness creation on the advantage of TIBF and avoidance of malpractices such as practicing PLF and delayed initiation of breastfeeding is needed. As well as promoting ANC visit and institutional delivery for all pregnant women is recommended for the increasing of TIBF. Therefore, to enable mothers to establish and sustain TIBF, it is crucial to increase a mother's level of knowledge of infant and young child feeding, as a cornerstone for implementing sustainable strategies to improve appropriate feeding practices.
Abbreviations ANC: Antenatal care AOR: Adjusted odd ratio CI: Confidence interval COR: Crude odds ratio EBF: Exclusive breastfeeding EDHS: Ethiopian demographic health survey PLF: Prelacteal feeding SDG: Sustainable Development Goals TIBF: Timely initiation of breast feeding WHO: World Health Organization.

Data Availability
All related data have been presented within the manuscript. The data set supporting the conclusion of this article is available from the corresponding author upon reasonable request.

Ethical Approval
Ethical clearance was obtained from the Institutional Review Board of Bahir Dar University, School of Chemical and Food Engineering, Department of Applied Human Nutrition. A letter of permission was also obtained from the Dire Dawa city health Bureau. The purpose of the study was explained for each mother.

Consent
At the time of data collection, written consent was obtained from each study participant for those ages greater than or equal to 18 years and from parents/guardians for those ages less than 18 years. All respondents assured that the data would not have any negative consequences on any aspects of their life.