Predictors of exclusive breastfeeding and maternal access to mobile phones in urban settings in Hawassa City, Sidama Region, Ethiopia

¹Hawassa University, Department of Human Nutrition, College of Agriculture, Hawassa, Ethiopia, ²School of Public Health, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia, ³Hawassa University, Department of Public Health, College of Medicine and Health Science, Hawassa, Ethiopia

^&Corresponding author
Sisay Tesfaye Yimam, Hawassa University, Department of Human Nutrition, College of Agriculture, Hawassa, Ethiopia

Introduction    

The act of feeding a baby only breast milk, either from their mothers, a wet nurse, or expressed breast milk, is known as exclusive breastfeeding. Except for some exclusions like oral rehydration solution drops or syrups containing vitamins, minerals, supplements, or medications authorized by a health practitioner from birth to six months of age, the infant is not given any other alternatives during the first six months of life, including liquids, solids, or even water [1]. It is well documented that breastfeeding provides many important health benefits to children and mothers and is considered the gold standard in infant feeding [2]. The benefits of breastfeeding include increased child survival, health, and development; it also lowers some health risks for women; it serves as a natural form of birth control; and it boosts both personal and societal economic growth [3].

Suboptimal breastfeeding practices, especially non-exclusive breastfeeding in the first six months of life, are contributing to the burden of childhood morbidity and mortality and are responsible for 45%, 30%, and 18% of deaths associated with infectious diseases, diarrhea, and acute respiratory diseases, respectively [4,5]. Over the last ten years, more than half of the world's population has transitioned to urban living, with 54% now residing in urban areas and expected to increase to 66% by 2050 [6]. With rapid urbanization in many low- and middle-income countries (LMIC), there are rapid changes in social behavior and health [7,8], which may contribute to the rapid decline in breastfeeding practice in many urban areas [9,10]. The Sustainable Development Goal (SDG) 2: zero hunger acknowledges that breastfeeding is the primary method for feeding infants and young children [11]. To strengthen the effort in reducing child mortality, the Ethiopian Ministry of Health (EMoH) had targeted an increase in the proportion of EBF for less than 6 months from 48% to 70% in 2015 [12].

They fell short of the target level set by the Sustainable Development Goals (SDGs) in low- and middle-income countries, especially in Africa. In 2017, only 37% of African newborns under six months of age received exclusive breast milk, and the prevalence of EBF varies by population and country [13]. The 2019 Ethiopian Demographic and Health Survey, 59% of infants 0-5 months and 7.5% of those at 6 months old were exclusively breastfed [14]. Proper breastfeeding habits depend on mothers' knowledge and their attitude [15]. In East Africa, 84.4% of women were aware of exclusive breastfeeding, and 96.2% of mothers had heard of it [16].

A study conducted in Lagos State, Nigeria, found that 89.2% of breastfeeding mothers demonstrated good breastfeeding knowledge [17]. In Rwanda, 78.9% of mothers had a positive attitude toward exclusive breastfeeding, and 85.6% of adolescent mothers understood it [18]. According to different studies conducted in Ethiopian cities, women in Jimma town (73.94%), Mizan Aman town (93.6%), and Bedele town (91.8%) have good knowledge of exclusive breastfeeding [19-21]. Therefore, most of the women had good knowledge of exclusive breastfeeding. The study in Hawassa city revealed that the age-specific prevalence of exclusive breastfeeding was 42.9%, 39.1%, and 18% at 1-1.9 months, 2-3.9 months, and 4-5.9 months, respectively. The 2019 Ethiopian health demography survey also shows similar results. This indicates that as the infant's age increases, the practice of exclusive breastfeeding declines [14,22]. A postnatal care visit is one of the ways to promote exclusive breastfeeding. However, a study in Northwest Ethiopia revealed that only 13.3% of women attended postnatal care visits. Other studies also indicated a low prevalence of postnatal care visits [23-26].

The study results in Ethiopia showed that 73% of moms without jobs and 54.8% of mothers with jobs exclusively breastfed. In the Somali region, women without jobs are more likely to breastfeed exclusively. Maternal employment with maternity leave was linked to exclusive breastfeeding [27-30]. Findings from routine monitoring and usability assessment showed that the mHealth application facilitated real-time information exchange in the primary health care system, as well as timely identification and registration of pregnant women, thereby increasing uptake of maternal health services across the continuum of pregnancy, childbirth, and postnatal care [31].

Therefore, exclusive breastfeeding practice was low and unsatisfactory due to maternal workload and insufficient maternity leave. Low coverage of postnatal care and traditional methods of exclusive breastfeeding promotion. Inadequate use of technology for real-time breastfeeding promotion. Urbanization is linked with the encouragement of formula feeding and a gap between knowledge and practical application. Therefore, this study intends to assess the current predictors of exclusive breastfeeding practice and maternal access to mobile phones and use for planning a short text message intervention in the study area. The findings inform policy decisions and best practices for national multi-sectoral food and nutrition interventions.

Methods     

Study design: a community-based cross-sectional study employing quantitative methods was carried out in Hawassa city from October to December 2024.

Study setting: Hawassa city is the capital of Sidama Regional State, located approximately 275 kilometers south of Addis Ababa, the capital city of Ethiopia. Hawassa is among the fastest-growing cities in Ethiopia. It is the region's main administrative, commercial, and industrial city. The city administration is divided into 8 sub-cities, 32 Kebeles (the lowest administrative structure), 1 (20 urban and 12 rural). It has an annual population growth rate of 4% [32]. The Ethiopian Central Statistical Agency estimates the population of Hawassa at 351,469 in 2018. In 2022, the Regional Health Bureau reported 26,602 people in the reproductive age group; 13,779 were males and 12,823 were females. The total estimated number of pregnant and lactating women in 2022 was 13,634, and the number of surviving infants was 12,853.

Study population: the study participants were selected mothers who had infants aged 0 to 6 months residing in the study area during the study period in Hawassa city.

Inclusion and exclusion criteria: all mothers who had infants aged 0-6 months and had been residents of the study area for more than six months, and who were able to provide consent during the study, were included. And those women's children with evidence of chronic health problems, who were unable to communicate, or who had chronic illnesses, were excluded.

Variables: the practice of exclusive breastfeeding was the outcome variable, while demographic characteristics, maternal and child health-related factors, knowledge, and attitudes served as independent variables.

Sample size determination: EPi- Info version 7.2.5.0 was used for sample size estimation. The sample size (n) was determined based on the single population proportion. The prevalence of mothers with a positive attitude towards exclusive breastfeeding, 37.6% was used from previous studies [33]. The level of confidence (α) was taken to be 0.05 (Z α/2 1.96) and a marginal error of 5%. The estimated sample size based on these assumptions was 360. A design effect of 2 was used to minimize the effect of cluster sampling, and a non-response rate of 10%, the total sample size required for the study was 772.

Sampling procedure: four sub-cities (50%) out of the eight sub-cities were randomly selected to make the sample more representative. The sample size was divided based on the proportion of the total number of lactating women found in each sub-city. The list of all lactating women was obtained from the health extension family folder. Mothers who lived in the area for at least six months and those who gave consent to participate in the study were eligible. The study participants were selected using simple random sampling by using a lottery method.

Data collection tools and techniques: the questionnaire was developed on paper and then uploaded to the Kobo Toolbox online tool. Once the questions were uploaded to the Kobo Toolbox, it was shared with the assessment team for review, testing, and finalization. Six data collectors and two supervisors were trained to participate in the data collection process. This study used a field-tested and validated questionnaire from the Food and Agriculture Organization of the United Nations (FAO), the Ethiopian Demographic Health Survey (EDHS) tool, and other literature [34]. The questionnaire was pretested on 5% of the total sample size in the adjacent kebele. Then it was checked for its clarity, consistency, and completeness, and the necessary corrections were made accordingly. The questionnaire includes socio-demographic, household characteristics, obstetric, and child health-related characteristics, knowledge, attitude, EBF practice, and mobile phone-related questions. The questionnaire was originally prepared in English and translated into Amharic by a language expert and back into English to ensure its consistency. The questionnaires were administered by interviewers to breastfeeding mothers selected from the source population.

Data analysis procedure: the data was downloaded into Excel and exported to SPSS for further statistical analysis. The first section included socio-demographic characteristics such as maternal age, religion, marital status, educational status, and occupation, followed by a descriptive analysis. Descriptive statistics, including frequencies, percentages, and cross-tabulation, were performed to describe sociodemographic, maternal, and child health characteristics and mobile phone use of the study participants. The knowledge section assessed maternal intellectual ability regarding exclusive breastfeeding practices. Ten knowledge questions were posed to determine the maternal knowledge level. One point was assigned for a correct answer, while zero was given for an incorrect answer, resulting in a minimum and a maximum score of zero and ten, respectively. Women who correctly answered all ten questions received ten points and were categorized as having good knowledge, while those scoring below ten were classified as having poor knowledge [34]. The third section assessed maternal attitudes towards EBF. A total of six questions were asked, and three responses were expected: favorable, neutral, or undecided, and unfavorable. Women's answers containing a favorable response were given three points, a neutral response two points, and an unfavorable response one point. The fourth section focused on maternal practices regarding exclusive breastfeeding. A total of four major points were considered, and women who correctly answered all four questions were considered as exclusively breastfeeding their infant until six months.

The first descriptive analysis was carried out to examine the distribution of each variable. Bivariate analysis was carried out to describe the association between the two variables. Finally, factors which was significant in the bivariate association were observed with a p-value of 0.25 and retained for subsequent multivariate analyses using multiple logistic regression to control for possible confounders. The adjusted odds ratio was used to measure the strength of the association between dependent and independent variables. A 95% CI was used to determine the significance of the associations with a p-value of less than 0.05. Hosmer and Lemeshow´s goodness-of-fit test checked the goodness of model fit, and logistic regression was run.

Ethical consideration: ethical approval was obtained from the Hawassa University Ethical Review Board, with reference number IRB/106/14. An official letter was issued from Hawassa University College of Agriculture, School of Human Nutrition and Food Science Technology, to the Hawassa City Health Department. In response, the health department sent an official letter to the public health center to obtain permission and support. The study's purpose was explained to participants, and oral consent was obtained to confirm their willingness to participate. Confidentiality of responses was maintained throughout the research process. All incomplete questionnaires were treated as non-responses.

Results     

Sociodemographic and economic characteristics of study participants: all study subjects, 772 mothers, participated in the study with a response rate of 100%. Out of 772 mothers, 757 (98.1%) were married. Concerning maternal age, 244 (31.6%) of the women were <25 years, and 291 (37.7%) women had an age range between 25 and 29 years, with a mean age of 27.7 (SD= ±4.2). Only 14 (1.8%) women led a household. The majority, 195 (47.4%) of the women, have an average monthly income of between 4,500 and 7,500 birr, followed by 169 (38.5%) of women who reported that their monthly income was between 1,500 and 4,500 birr. Educational status: 283 (36.7%) of women achieved secondary education, 226 (29.3%) attended primary school, 156 (20.2%) attended vocational training, and the rest were university graduates, and a few others had never attended. All the households have electric light sources and toilets. Maternal employment, majority, 315 (40.8%) of the women were housewives, 216 (28%) were private employees, 150 (19.4%) were government employees, and 91 (11.8%) of the women were students (Table 1).

Maternity and infant-related characteristics: the marital age of the women, 439 (56.9%), was ≥ 20, and 333 (43.1%) were ≤ 20 years. All (100%) women had antenatal care visits, and among them, 545 (70.6%) had four or more visits. Regarding methods of delivery, 531 (68.8%) gave birth by spontaneous vaginal delivery, and 241 (31.2%) by cesarean section. A greater part, 771 (99.9%), of women delivered their babies at a health facility. Postnatal care utilization was 197 (25.5%) of women had four or more visits, 256 (33.2%) of women had three visits, 287 (37.2%) of women had two visits, and the others had only one visit. Of the number of deliveries, 496 (64.2%) gave birth more than once, and 266 (34.5%) gave birth only once. Infant sex, 436 (56.5%) were females and 336 (43.5%) were males. The age group of the infant 364 (47.2%) was 2-4 months, 278 (36.0%) was 4-6 months, and 130 (16.8%) was 0-2 months. The mean age of the infants was 3.8 (SD=±1.2) months (Table 2).

Knowledge of exclusive breastfeeding among women: the study revealed that 741 (96.0%) of participants had adequate knowledge about breastfeeding, with a mean (±SD) score of 8.02 (±.1.34), and 767 (99.4%) had heard about breastfeeding. Seven hundred and twenty-eight (94.9%) reported that they knew about exclusive breastfeeding. Six hundred and forty-six (83.7%) and 704 (91.2%) of the respondents said that breast milk alone was the first food for the newborn and adequate for the first six months of age, respectively. About 614 (79.5%) of the women reported that breast milk was given eight or more times daily. Most respondents, 747 (96.8%), reported that exclusive breastfeeding is given for the first six months, and 416 (53.9%) of the moms know different ways of increasing breast milk supply. More than half, 523 (67.7%), 553 (69.0%), and 558 (72.3%) of women reported that breast milk offers benefits for the child, mother, and the country, respectively. About 416 (53.9%) of mothers knew about maintaining breastmilk supply.

Maternal attitude towards exclusive breastfeeding practice: about 460 (59.6%) of women have a favorable attitude towards exclusive breastfeeding. About 756 (97.9%) of women felt positive, and 656 (86%) of the women reported no difficulties in exclusively breastfeeding for six months. A high proportion, 748 (96.9%), of moms felt good about giving breast milk to their infants on demand. More than half, 510 (66.1%) of women, felt confident in expressing and storing breast milk.

Infant breastfeeding practice based on the 24-hour recall: the prevalence of exclusive breastfeeding was 54.4% (95% CI: 50.8, 58.0). The age-specific prevalence of EBF was 15.7% for 0-2 months, 32.4% for 2-4 months, and 6.3% for 4-6 months (Figure 1). The sex-specific prevalence was 24.0% for males and 30.4% for females (Figure 2). Most women, 676 (87.6%), started breastfeeding immediately after birth. Additionally, 742 (96.1%) women gave their infants their first milk (colostrum).

Ownership of mobile phone health (mHealth) and related characteristics: in this study, 772 (100%) mothers reported owning mobile phones. About 569 (73.3%) have experience in sending and 587 (76%.0) receiving SMS text messages using their mobile phones. Among respondents, 649 (84.1%) were willing to receive SMS text messages, and 494 (64.0%) of the women preferred receiving an SMS text message at any time. In this study, only 49 (8.3%) women received health-related SMS using mobile phones. About 656 (85.0%) of respondents preferred the Amharic language (Table 3).

Predictors of exclusive breastfeeding practice: logistic regression analysis was used to identify the variables affecting exclusive breastfeeding practice and to control the influence of confounding variables. Bivariate and multivariate analyses were performed, with PV<0.05 and 95% CI used as criteria. Maternal knowledge, age, level of education, monthly income, marital age, number of ANC visits, type of delivery, number of PNC visits, and husband's support were associated with exclusive breastfeeding practice in the bivariate analysis. Multivariable logistic regression was then performed to control the effect of confounding variables. logistic regression analysis was used to identify the variables affecting exclusive breastfeeding practice and to control the influence of confounding variables. Bivariate and multivariate analyses were performed, with PV< 0.05 and 95% CI used as criteria. Maternal knowledge, age, level of education, monthly income, marital age, number of ANC visits, type of delivery, number of PNC visits, and husband's support were associated with exclusive breastfeeding practice in the bivariate analysis. Multivariable logistic regression was then performed to control the effect of confounding variables. Women´s knowledge, age, postnatal care, maternal employment, maternal level of education, and husband support become strongly associated factors after being adjusted for potential confounding variables. Compared to breastfeeding women with inadequate knowledge, those with good knowledge were 3.50 times more likely to practice exclusive breastfeeding (AOR =3.5, 95% CI: 1.48, 8.29). The odds of exclusive breastfeeding practices among mothers aged 25-29 and 30-34 years old were 61% and 70% less likely to practice EBF compared to mothers 35 years and above, respectively. Compared to women with a university degree, women with vocational training and secondary school education were 2.62 times (AOR =2.62, 95% CI: 1.37, 5.00) and 3.20 times (AOR =3.20, 95% CI: 1.53, 6.67) more likely to practice EBF, respectively. Compared to student mothers, exclusive breastfeeding was linked with 2.77 times higher odds in government-employed women (AOR = 2.77, 95% CI: 1.35, 5.67), and 2.51 times higher odds in private-employed women (AOR = 2.51, 95% CI: 1.42, 4.44). Women with husband support were 2.11 times more likely to breastfeed than those with no support (AOR =2.11, 95% CI: 1.41, 3.16) (Table 4).

Discussion     

This study indicated that 54.4% (95% CI: 50.8, 58.0) of mothers exclusively breastfed their infants in the first six months. A similar study conducted at Bahirdar city revealed that 57.3% (95%CI: 52.3%-62%) of women were exclusively breastfed until six months [35]. This study was also higher than the study conducted in Harar town, 45.8% of women practiced exclusive breastfeeding [36]. And also lower than the Ethiopian mini-demographic health survey (59%), because this survey included the rural areas' research findings [14]. A study conducted in some rural areas of Ethiopia the prevalence was relatively higher than in the urban areas. Offa district of Wolayta Zone, 78.0%, Goba district of Oromia region, 71.3%, in Debre Tabor town of Amhara region, 70.8%, and Azezo district, Northwest Ethiopia, 79% [37-40]. However, this result was less than that of a 2017 study conducted in one of Hawassa's rural sub-cities (60.9%, 95% CI: 56.6, 65.1) [41]. This indicates that the rate of exclusive breastfeeding varied between urban and rural areas; as a result, alternative promotional approaches to exclusive breastfeeding should be used to raise the rate in urban areas.

This study indicated that 96.0% (95% CI: 94.7, 97.4) of mothers have good knowledge of exclusive breastfeeding. This finding was higher than the findings of a study in North West Ethiopia, 92.1% (95% CI: (89.5-94.6), and South West Tanzania, 77.7 % [42,43]. Similarly, the study conducted in Lagos State, Nigeria, showed that 94% had good knowledge of exclusive breastfeeding [17,43]. Despite good knowledge, low postnatal care follow-up for counseling, lack of continuous family support, and weak and inadequate reminder strategies remain reasons for the low rates of exclusive breastfeeding in urban areas [23,24,44-46].

Women's attitudes regarding exclusive breastfeeding were also evaluated. More than half, 59.6% (95% CI: 56.2, 62.8) of women had a positive attitude about it. A study on breastfeeding women in Jimma was 63.99%, and in Lagos State, Nigeria, it was 90%. In Rwanda, it was found that 78.9% had a positive attitude towards breastfeeding, which was higher than in the current study [17-19]. Despite a positive attitude, women have limited practice towards exclusive breastfeeding.

Regarding women's access to cell phones, 48.5% and 51.4% had a smart and standard phone, respectively. Among the participants women 84.1% of women were willing to receive SMS texts. Amharic was the language that 85% of them preferred. The survey in Northwest Ethiopia found that 37.6% of people had a smartphone, and 76.7% of people owned a mobile phone, which is lower than the current study [47]. A survey conducted in Gulu, Uganda, most of the women consistently stated that they would be amenable to receiving health messages on their mobile phones [48].

In this result, a large proportion of women who own a mobile phone have experience reading, receiving, and sending SMS messages. Their willingness to receive text messages is very high, which will create an opportunity for researchers and healthcare providers to offer real-time breastfeeding information and counseling. The multivariate regression statistics showed that there was a significant relationship between knowledge and exclusive breastfeeding; those women who have good knowledge are 3.50 times more likely to practice exclusive breastfeeding than those who have poor knowledge (AOR = 3.50, 95% CI = (1.48, 8.29). Maternal knowledge played a key role in exclusive breastfeeding practices. The current result was consistent with the cross-sectional study conducted in Gambia, Banjul, where 60.2% of breastfeeding women had good knowledge, but only 38.6% of women breastfed their infants [49]. Similar studies conducted in Abuja, Nigeria [50]; Southwest Tanzania [43]; Italy [51]; Northwest Ethiopia [42]; and Tigray Mekele [52] have shown that good knowledge becomes a predictor of exclusive breastfeeding practice.

Compared to women with no education and university degrees, breastfeeding women with vocational training were 2.62 times more likely to perform EBF (AOR = 95% CI = (1.37, 5.00) and those with secondary school education were 3.20 times more likely to do so (AOR = 95% CI = (1.53, 6.67). A similar study done in Indonesia, breastfeeding women with elementary, junior, and high school grades were 1.167 times, 1.203 times, and 1.177 times more likely to exclusively breastfeed, respectively, than mothers without such records [53]. Additionally, compared to breastfeeding women without education, mothers in sub-Saharan Africa who completed elementary school were 1.37 (95% CI AOR: 1.27 to 1.48) times more likely to exclusively breastfeed. In terms of EBF practices, women with a secondary education did not differ substantially from mothers without education [54].

Women who have their husbands' support are also 2.11 (AOR=2.11, CI: 1.41, 3.16) times more likely to exclusively breastfeed than those who do not (OR = 95% CI: 1.41, 3.16). This study was comparable to those carried out in Mekele, Tigray, Ethiopia, Bahir Dar town, northwest Ethiopia (AOR = 4.15, 95% CI: 2.13, 6.28), and Boyolali, Indonesia (p = < 0.001, 95% CI: 1.669-5.383). Different studies also indicated that fathers' support has a positive impact on exclusive breastfeeding practices [35,55].

Limitations of the study: since the study was conducted in an urban community, the findings may not apply to the entire community. The study was not based on direct observation or practical intervention but on women´s answers to a questionnaire.

Conclusion     

According to the study, the rate of exclusively breastfed (EBF) infants under six months of age was lower than the national recommendation. Nonetheless, there is a positive attitude and good knowledge regarding exclusive breastfeeding. Maternal knowledge, age, level of education, occupation, and husband support were predictors of exclusive breastfeeding. A significant number of urban lactating mothers have access to a mobile phone and know how to send, receive, and read SMS messages. This will allow researchers and health care providers to provide breastfeeding information and counseling in real time. Improving the rate of exclusive breastfeeding is necessary to meet the national target and the Sustainable Development Goal (SDG). Therefore, a more extensive and comprehensive counseling approach, along with real-time information, would be a key strategy to improve exclusive breastfeeding rates among the urban population.

Competing interests     

The authors declare no competing interests.

Authors' contributions     

Sisay Tesfaye served as the principal investigator and contributed to idea generation, proposal development, data collection, analysis, writing the original manuscript, selecting the journal, and submitting the paper. Dejene Hailu and Samson Gebremedhin provided technical support in proposal development, research methodology, data analysis techniques, and offered helpful comments on manuscript writing and final approval.

Acknowledgments     

We are grateful to the School of Human Nutrition and Food Science Technology at Hawassa University College of Agriculture. We would also like to thank the data collectors and supervisors for their efforts in contributing to this research. We extend my gratitude to the study participants for their participation. Finally, we would like to extend my special thanks to the Hawassa City Administration Health Department and their staff for sharing the demographics and data necessary for this study.

Tables and figures     

Table 1: socio-demographic characteristics of lactating women at Hawassa city, Sidama region, Ethiopia, December 2024

Table 2: maternal and child health-related characteristics of lactating women at Hawassa city, Sidama region, Ethiopia, December 2024

Table 3: maternal access to mobile phone and related characteristics of lactating women at Hawassa city, Sidama region, Ethiopia, December 2024

Table 4: factors associated with exclusive breastfeeding practice among lactating women at Hawassa city, Sidama region, Ethiopia, December 2024

Figure 1: infant breastfeeding practice by the sex of the infant at Hawassa city, Sidama region, Ethiopia, December 2024

Figure 2: infant breastfeeding practice by the age group of the infant at Hawassa city, Sidama region, Ethiopia, December 2024

References