Colostrum Feeding Practices and Associated Factors Among Mothers Having Children Less Than 12 Months of Age in Wolaita Sodo City, Wolaita, Ethiopia 2019

Back ground: Colostrum is the principal milk produced in the first few days after delivery. It is a normative ordinary for the newborns concerning the comprehensive form of nutrition which is well thought –out as the “golden milk” is highly nutritious and contains anti-infective substances. It is very rich in vitamin A, protein and recommended as the newborns’ absolute nourishment by UNICEF and WHO that should begin soon after delivery. The main purpose of this study was to assess colostrum feeding practices and associated factors among mothers having children less than 12 months age in Wolaita Sodo City, Wolaita, Ethiopia. Methods: A community-based cross-sectional study was employed from May 31 to Sep 31 2019 in Wolaita Sodo City. The data collected by using interview-based structured questionnaires among 396 eligible mothers through a systematic sampling technique. Data was analyzed by using SPSS version 25. Both binary and multiple Variable logistic regressions (“odds ratio”) analyses with a p-value < 0.0 5 with 95% confidence interval were identified as statistically significant. Result: Three hundred fifty seven, 87.4% (95%, CI: 11: 0014:00) of mothers practiced colostrum feeding after delivery. In multivariate logistic regression analysis at P-value of < 0.05, Counseling on timely initiation of breastfeeding during antenatal care (AOR=7.798, 95% CI: 2.64-23.01), place of delivery (AOR=4.010, 95% CI: 1.260-12.760) and birth attendant of the current birth (AOR=3.119, 95% CI: 1.263-7.706) had the significant association with colostrum feeding practice. Conclusion: Counseling provided on early initiation of breastfeeding during antenatal care, giving birth at health care facilities and attending delivery by health care professionals were predictors of colostrum feeding among mothers having infants less than 12 months of age. Strengthening education on timely initiation of breastfeeding during antenatal care, promoting to give birth at health care institutions and accessing delivery attendance by health care workers are essential for colostrum feeding. Sustaining awareness creation strategies and approaches were suggested for the advancement of the nutritional value of colostrum and its health welfares for new born babies.


Introduction
Child death is high internationally when equated to other age categories and greater than 75% happens in unindustrialized nations. Colostrum is the first liquid that is produced in the first few hours after delivery. Timely feeding of it to the newborn babies is continued as significant to challenge child nutrition and also the existence of newborn as revealed by scientific evidence [1][2][3]. Colostrum contain less amounts of lipid and potassium than usual milk [4,5] It is helpful for bodily growth and intellectual development and has also laxative effect which encourages passage of baby's first stool which helps to prevent jaundice by clearing excess bilirubin that is created in large quantities at birth [1]. It contains various maternal immunoglobulins and is thick, sticky and clear to yellowish in color. It has proteins, vitamin A and maternal antibodies important to the newborn's nutrition until lactation is fully established and it has also high amounts of sodium, potassium, chloride, and cholesterol and various cytokine and growth factors which combination is supposed to encourage peak development of the infant's heart, brain, and central nervous system [1][2][3][4]. In a word it acts as a natural vaccine and ultimately reduces the leading causes of death like diarrhea and acute respiratory Infections (ARI) in developing nations of the World [1,2]. Colostrum has a positive consequence in the prevention of juvenile malnutrition [1] and also delivers natural immunity (baby's first immunization) against many bacterial and viral infections through establishing important bacteria in the baby's gut [2][3][4]. Despite colostrum having these merits, it is rejected in some communities because it is taken as heavy, thick, dirty, toxic [1] and dangerous to children's health [1][2][3][4]. Inappropriately, colostrum feeding is not initiated to newborn soon after delivery for different communal mythologies and misunderstanding. These artificial problems distress directly and indirectly the health of newborn infants and results in malnutrition and high mortality rate in infants [1]. Suboptimal breastfeeding is accountable for 45% of newborn communicable mortality, 30% of diarrheal deaths and 18% of severe respiratory deaths among children less than five years of age [1,2]. In Ethiopia, about 18% of the infant deaths have been credited to deprived feeding practices [1][2][3]. Although colostrum feeding provides newborns with immunity to infection, any practice that reduces a frequency or volume of breastfeeding during this time could reduce an infant's long-term health and immunological defense [1,2]. Even though the world health organization (WHO) recommended initiating colostrum feeding within the first hour of birth [1], a higher number of mothers avoided their colostrum before giving milk to their infant [1][2][3][4][5]. Mothers living in under developed countries avoid colostrum due to outdated views [1][2][3]. Prolonged labor, cesarean delivery, lack of knowledge regarding the benefits of colostrum and neonatal illness are the factors of colostrum's feeding [1][2][3]. Even though Ethiopia has developed the National Infant and Young Child Feeding guideline which recommends colostrum feeding [1,2]. There is wide variability towards colostrum feeding practice and discordant findings in different regions of Ethiopia [1][2][3][4][5] but no study was done on the feeding practices of colostrum and factors related to it in Wolaita Sodo City. Hence, this study aimed to investigate colostrum feeding practices and factors associated among mothers having children aged <12 months in Wolaita Sodo City, Wolaita, Ethiopia

Study Area and Setting
The study was carried out in Wolaita Sodo city. The city has a total population of 250521. From this, about 4752 mothers have infants less than 12 months of age. The city has three sub cities and 24 kebeles. Wolaita Sodo City has three health centers, one teaching and referral hospital owned by MOH and one private general hospital. The Wolaita Sodo city is located from 327 km from Addis Ababa, the capital of Ethiopia (11).

Study Design and Period
A community-based cross-sectional study was employed from May 31 to Sep 31 2019 in Wolaita Sodo City, Wolaita, Ethiopia

Source Population
All mothers having children less than 12 months of age in Wolaita Sodo city

Study Population
Selected mothers who have a child less than 12 months of age at the time of data collection in Wolaita Sodo City

Inclusion Criteria
Mothers who have a child less 12 months of age, resided in study area for at least six months and provided informed consent during the period of data collection

Exclusion Criteria
Mothers who were seriously ill and not volunteer to participate in the study

Sample Size Determination
Sample size was calculated with Epi info statistical software version 3.03 using single population proportion statistical formulas and considering colostrum feeding practice in Aksum town from the previous study as 86.5 n=Z (1.96) 2 P (1-P)/ d 2, where n=the sample size⌠ z=the level of confidence (1.96) 2 with 95% CI p=the proportion of colostrum feeding practices of mothers having children less than 12 months age in Raya Kobo District 86.5% (12) d=margin of error Sample size calculation: Colostrum feeding practice=86.5 n=( /2) 2 . P (1-P)=(1.96) 2 . 0.865 (1-0.865)÷ (0.05)=180 d 2 Taking the design effect as 2 and considering 10% nonrespondent rate with confidence levels of 95% and 5% margin of error.
nf=final sample size was 396

Sampling Procedure
The multi stage sampling technique was used to select study population at the community level. First 8 kebeles were selected from the total of 24 kebeles. A sample size of 396 mothers who have a child with the age less than 12 months old from each kebele were selected based on proportional allocation to the sample size was done. Systematic sampling technique (k=12) was used to choose the household for an interview and the starting mother was selected using a lottery method. In the households with more than one child less than 12 months, the youngest child was selected randomly. The actual age of the infants was determined by asking the mothers and reviewing the birth date from vital certificate.

Dependent Variable
Colostrum feeding practice.

Independent (Exposure) Variables Related to Maternal Socio-demographic and Economic Factors
Age of the mother, sex of the child, monthly income, family type, occupation of the mother, educational status of mother, educational status of father.

Independent Variables Related to the Maternal
Health Service Utilizations ANC follow up, counseling during ANC, birth order of the child, mode of delivery, place of delivery, birth attendants, and timely initiation of breastfeeding.

Operational Definitions
Colostrum: it is the yellowish breast milk created with in the first few days after delivery.

Data Collection Instrument
Structured, pre-tested and interviewer administered questionnaires were used. Questions on the questionnaire include the socio demographic characteristics, health service utilization, obstetrics and breast feeding related issues. The questionnaires were from the World Health Organization indicators for assessing infant and young child feeding practices and by adapting to the Ethiopian context.

Data Collection Procedure
Data were collected through face-to-face interview maintaining the predetermined sampling intervals by 5 professional nurses and 5 Health Officers. The principal investigator supervised data collectors. The data collectors informed the respondents all details of the research purpose and procedures and what was expected of them, potential risk and benefit in order to encourage accurate and honest response. When the mother was not available on the first visit, data collectors arranged alternative visits. If a woman was still not available on second visits or declined to participate in the study, the household was jumped and the immediate next household in the sampling frame was considered.

Data Quality Management
Before data collection, the questionnaire was first prepared in English and translated into Amharic and back to English to keep the consistency of questionnaire. Three days training was given to data collectors and supervisors by the principal investigator before the actual data collection.
A pretest was conducted in Bodit town on 5% of total sample size was tested. Based on the pretest, questionnaires were revised, edited and the necessary corrections made accordingly. The collected data were reviewed and checked for completeness and consistency by the supervisor and principal investigator on a daily basis.

Data Processing and Analysis Procedures
The data were coded, cleaned, entered and edited was done by using EPiData version 3.1 and exported to SPSS version 25 for analysis. Binary logistic regression analysis was employed to scan the statistical association between the outcome variable and every single independent variable. Variables which revealed statistical significance during bivariate analysis at ≤ 20% (p-value ≤ 0.2) were arrived into multivariate logistic regression to quarantine an independent effect of the predictors by using the backward removal method. The Hosmer-Lemeshow test was used to check the appropriateness of the model for analysis. Results were presented using tables and texts. Adjusted odds ratios (AOR) with 95% CI, were estimated to assess the strength of associations and statistical significance was stated at a pvalue < 0.05.

Ethical Issues
Ethical clearance was obtained from Wolaita Sodo University Institutional Review Board (IRB). Written consent was gotten from Wolaita Sodo city health department. During data collection all respondents were asked their authorization and informed consent was signed from each study participants.

Results
Socio-demographic and economic characteristics of the respondents All eligible mothers of this study were agreed and participated in this study making the response rate of (100.00%). The mean age of mothers participated in this study was 25   Colostrum feeding practice and related characteristics of mothers From the 396 mothers who participated in the study, 312 (78.8%) initiated feeding their infants within one hour of delivery. About 346 (87.4%) of mothers provided colostrum for their infants, 356 (87.3%) were feeding their infants based on demand of the child (Table 4). Factors associated with colostrum feeding practices In the binary logistic regression at a p-value of ≤0.25, family type, family income, exposure to mass media, ANC follow up, number of ANC follow up, counseling on timely initiation of breastfeeding during ANC visit, Early initiation of breastfeeding after delivery, place of delivery, birth order and birth attendant were statistically associated with colostrum feeding practice.
In multiple logistic regression by using backward elimination technique, mothers who have counseling on timely initiation of breastfeeding during antenatal care were 7.798 times higher to practice colostrum feeding than those mothers who have not counseled on timely initiation of breastfeeding (AOR=7.798, 95% CI: 2.64-23.01), mothers delivered at health care facilities were 4.010 times more to practice colostrum feeding than their counterparts. (AOR=4.010, 95% CI: 1.260-12.760) and mothers attended by health care professionals have 3.119 times more likely to provide colostrum for their infants than those mothers assisted by non-health care workers (AOR=3.119, 95% CI: 1.263-7.706) had the significant association with colostrum feeding practice (Table 5).

Discussion
The main reason of this particular study was to assess colostrum feeding practice and its associated factors amongst mothers having infants less than 12 months age in Wolaita Sodo City. This study has shown that the magnitude of colostrum feeding practice was 87.4% which is consistent with the finding reported from Raya Kobo district, Kombolcha town and North Wollo Zone respectively [20,25,27]. The result of this study is lower than similar study done at Aksum town which was found to be 94.7% [26]. The finding from the current study is almost similar to the report from North Wollo zone which was 88% [25]. The finding of recent study was greater than similar studies done at Debre Tabor town [28] and Northern part of Ethiopia [13]. The differences among these current and previous studies may be due to period of the study, socio-demographic and economic disparities, socio-cultural variability among the study participants, differences in the study design and sample size.
The finding from current study is higher than the similar studies done in different developing countries which was 79% in Assam, India [19], 63% in Bangladesh [29], 69% in Nepal and 83% in South Africa [29,30]. The result from the recent study is lower than similar study in Burkina Faso which showed colostrum feeding 92% and 97% in Uganda respectively [30]. The differences may be due to crosscultural, educational, infant feeding styles and residential dissimilarities.
Counseling given for prenatal mothers on timely initiation of breastfeeding during antenatal follow up heightens the feeding practice of colostrum. The mothers who got counseling on early initiation of breastfeeding practiced colostrum feeding 7.798 times higher than their counterparts. The finding is similar to studies in the Northern part of Ethiopia [25,26]. This may be due to creation of awareness towards advantage of colostrum to their infants during promotion of timely breastfeeding initiation. Recommending timely breastfeeding during pregnancy may also keep the place for mothers to discuss the essentials of colostrum for their newborn critically.
The odds of colostrum feeding practice among mothers who delivered at health care facilities were 4.010 times higher than those who gave their current birth at home. This is in line with the study done at North Wollo Zone [25]. The lower odds of colostrum feeding at home delivery could be due to the pressure from family members, friends or significant others. The higher odds of mothers who delivered at health institutions can be because of information from the birth attendants, counseling on colostrum advantages during immediate postnatal period or delayed breastfeeding initiation after delivery.

Conclusion
Counseling provided on early initiation of breastfeeding during antenatal care for antenatal care mothers, place of delivery and birth attendants were predictors of colostrum feeding practice among mothers having infants less than 12 months of age. Strengthening education on timely initiation of breastfeeding during antenatal care, promoting to give birth at health care institutions and accessing delivery attendance by health care workers are essential for colostrum feeding. Sustaining awareness creation strategies and approaches were suggested for the advancement of the nutritional value of colostrum and its health welfare for new born babies.
Based on the finding from current study, it is better to provide culturally tailored health education for pregnant mothers by health extension workers focusing on the essentials of colostrum feeding for the betterment of their babies.

Strength of the Study
The study tried to address mothers recall bias by limiting the infants age to less than 12 months. Rather than facility based study, community centered study was used to reduce the social desirability bias. The protective relationship between colostrum feeding practices and risk was demonstrated after controlling for factors that are known to be associated with colostrum feeding experiences. This particular study also tried to limit sample related issues. Another strength may be, this is the first study on colostrum feeding at the study area in particular to address issues related early breastfeeding problem

Limitations
The evidence obtained from mothers might be exposed to memory bias since the data were gathered grounded on selfreport of the mothers of infants aged less than 12 months age. Lack of support with qualitative data may be another short back. The study also shares some constraints of crosssectional study design.

Abbreviations
UNICEF: united Nations children's fund WHO: world health organization SPSS: statistical software for social sciences P-value: probability value CI: confidence interval AOR: adjusted odds ratio ARI: acute respiratory infections IYCF: infants and young child feeding MOH: minister of health ANC: antenatal care Epi info: epidemiological information IRB: institutional review board

Ethical Approval and Consent to Participate
The ethical clearance for this study was proven by the Wolaita Sodo University institutional review board and a supportive letter was obtained from the Wolaita Sodo City health department office. The study participants have fully informed on the purpose of the study and information was collected after obtaining written informed consent from each participant. Information was documented secretly and confidentiality was guaranteed during the study period.

Data availability and Materials
The datasets used during the current study are available from the corresponding author on reasonable request.

Conflicts of Interest
The author declare that there is no conflict of interest.

Funding Source
This study has no funding source.