Determinants of pre-lacteal feeding practice in Ethiopia: Evidence from the 2019 Mini Demographic and Health Survey (MDHS), a community-based cross-sectional study

Background

Breastfeeding at birth plays an important role in determining the health of a child, and it is a means of contributing to the UN’s Sustainable Development Goals (SDGs). These include a focus on ending all forms of malnutrition globally by 2030,^1,2 particularly for those less than six months of age, and on achieving 2025 internationally agreed targets on stunting and wasting in children less than five years old.³ In recognition of the benefits of human breast milk, particularly when infants are exclusively breastfed, the World Health Organization (WHO) and United Nations Children’s Fund (UNICEF) advise against pre-lacteal feeding for infants within the first six months of life, unless medically indicated.^1,4

Globally, children under the age of five years account for 60% of the 10.9 million deaths that occurred annually. More than two-thirds of deaths are linked to poor feeding practices during the first year of life.⁵ Breastfeeding has the potential to save the lives of neonates, infants, and young children, as well as to reduce morbidity. Every day, 3,000 to 4,000 infant deaths occur in developing countries, most of them as a result of problems arising from breastfeeding issues, such as diarrhea and acute respiratory infections.^6,7

Pre-lacteal feeding is the practice of giving an infant foods or liquids other than breast milk during the first three days after birth.^8,9 It is the most significant impediment to exclusive breastfeeding and the significant predictor of infant mortality and morbidity.^10,11 Globally, almost two out of every five breastfed newborns received pre-lacteal foods and liquids.¹² Honey, butter, goat’s milk, cow’s milk, boiled water, and clean water are the most common pre-lacteal foods and liquids that are usually given to newborns.^13–16 Pre-lacteal feeding deprives an infant of essential nutrients during the first six months of life.¹⁶ Every year, inadequate breastfeeding practices, including pre-lacteal feeding, harm 823,000 children under the age of five years.^17,18

The evidence has suggested that improving breastfeeding practices, such as avoiding pre-lacteal feeding, starting breastfeeding within the first hour of life, and breastfeeding on demand could save the lives of over 820,000 children each year.^4,18 However, many infants did not receive such optimal feeding practices, and died from various easily preventable diseases. It has previously been established that pre-lacteal feeding is harmful and can expose infants to the risk of infection.¹⁹ Furthermore, it has been found that pre-lacteal feeding is responsible for 45% of neonatal infectious deaths, 30% of diarrheal deaths, and 18% of acute respiratory deaths in children.^4,20 Additionally, newborns that were exposed to pre-lacteal feeding were more likely to be stunted or wasted than those who were exclusively breastfed.^19,21

According to various local and national studies, pre-lacteal feeding is a common and widespread practice in Ethiopia.^6,14,22–27 However, these works indicate that there is a paucity of information about the causes of pre-lacteal feeding. Thus, one of the most accurate pictures of the prevalence of pre-lacteal feeding is found in the national data source, the Ethiopian Mini Demographic Health Survey (MDHS), which was conducted in 2019. The purpose of our study was to examine the determinants of pre-lacteal feeding practice among mothers who had a live birth child under the age of 24 months, in Ethiopia, 2019.

Methods

Study variables

The dependent variable of our study is pre-lacteal feeding practice. The independent variables were socio-demographic variables (like maternal age, educational status, religion, place of residence, region, marital status, child’s sex, socio-economic position (wealth quintile), and family size); maternal health service utilization factors (like antenatal care, iron taken during pregnancy, place of delivery, mode of delivery, breastfeeding initiation time, health checked after delivery at home, health checked before discharge from hospital, and child health checked within two months); and maternal and birth-related factors such as age at first birth, parity, number of under-five children, and number of ever-born children. Information about all these independent variables was collected and included systematically in the 2019 EDMHS.

Figure 1 shows a schematic presentation of the sampling procedure for those mothers who had a live birth child under the age of 24 months in Ethiopia, 2019, based on data sourced from the 2019 EMHDS.

Figure 1. Schematic presentation of the sampling procedure for those mothers who had a live birth-child under the age of 24 months in Ethiopia, 2019, based on data sourced from the 2019 EMHDS.

Results

Discussion

Breast milk contains all of the nutrients required for children in their first six months of life, and the World Health Organization recommends starting breastfeeding within one hour of birth and exclusively breastfeeding for the first months. Pre-lacteal feeding, on the other hand is widely practiced in Ethiopia,^9,14,30,31 Thus, in the current study pre-lacteal feeding was practiced by 12.1% (95%CI: 10.30%-13.9%). However, this was lower than that found in other studies conducted in Vietnam (73.3%³²), Nigeria (26.5%³³), Pakistan (64.7%³⁴), the Himachal Pradesh district of India (49.5%³⁵), Egypt (58%³⁶) and in other local studies conducted in some districts of Ethiopia (Dire Dawa, 15.7%,⁹ Raya Kobo district, 38.8%,¹⁴ Harari region, 45.4%,³⁰ and Kersa district, 46.6%³¹). This variation in pre-lacteal feeding could be attributed to socio-cultural differences between countries and districts. Furthermore, the current study concentrated on the national demographic health survey, which covered a wide proportion of the population. However, the figure is higher than that found in the 2016 Ethiopia Democratic and Health Survey (EDHS) which was 8%.²³ This disparity could be attributed to an increase in caesarian section delivery, during which mothers were started on pre-lacteal feeding other than breast milk until they recovered from the anesthesia injection. Our study is also in line with other studies conducted in Ethiopian districts including Axum town (10.1%), Bure district (11.6%), Jinka town (12.6%) and Mettu district (14.2%).^27,37–39

In our study, we identified that region, ANC visit, place of delivery, mode of delivery, and breastfeeding initiation time were significantly associated with pre-lacteal feeding practice in Ethiopia. Thus, we found that mothers who did not attend an ANC visit were 3.8 times more likely to practice pre-lacteal feeding than those who attended four or more ANC visits. This is consistent with other studies conducted in India³³ and in the Harari and Mettu districts of Ethiopia.^30,37 In addition to this, the odds of pre-lacteal feeding has increased by 65% in mothers who attended 1-3 ANC visits as compared with those who attended four or more visits. A possible explanation is that ANC use increases women’s awareness of the benefit of optimal breastfeeding and the danger of using pre-lacteal foods or liquids for the newborn.

According to our results, mothers who gave birth at home were 1.7 times more likely to practice pre-lacteal feeding than those who gave birth in a health facility. This is consistent with the finding of a study conducted in the Kersa district of Ethiopia³¹ and EDHS 2016.²⁹ However, it is lower than the findings of other studies conducted in Raya Kobo district, Mettu district, Bure district, Jinka town, and India.^{14,30,37–39} The possible explanation is that institutional delivery is a point of contact for labour mothers, where there is the initiation of a postnatal care (PNC) service for the mother and newborn care, and where healthcare professionals counsel the mother to refrain from exclusive breastfeeding practice for the first six months. Furthermore, giving birth at home creates a favorable environment for local community members, who may advise the use of pre-lacteal feed, thereby influencing newborn feeding practice.

Regional variation was found to be a predictor of pre-lacteal feeding practice in our study, with mothers living in pastoralist regions being 3.2 times more likely to practice pre-lacteal feeding than those living in urban regions. This was due to the fact that most pastoralist communities did not have a permanent residence. Thus, an equitable distribution of basic health services, particularly maternal and child health services and adequate access to information and resources, are hard to achieve for these groups, lessening a mother’s awareness of the dangers of pre-lacteal feeding for the newborn child. Aside from these possible explanations, the pastoralist community has a variety of traditional and cultural breastfeeding practices that may encourage/enable the mother to practice pre-lacteal feeding.

Our study also showed/emphasized the link between mode of delivery and mothers’ pre-lacteal feeding practice. Thus, our findings revealed that women who had caesarian section delivery were 3.7 times more likely to engage in pre-lacteal feeding practices. This result is consistent with studies conducted in Pakistan,³² India,³⁵ and different studies in the Ethiopian districts of Dire Dawa, Aksum, and Metu.^9,27,37 However, it is lower than in Nigeria’s study (1.5 times).³³ The possible explanation is that the caesarian section post-anesthesia/post-operative effect may interfere with immediate colostrum feeding and delay breastfeeding initiation. As a result of this interference and delay, the mother may be compelled to initiate feedings other than with breast milk.

The proper implementation of Baby-Friendly Hospital Initiatives is a key solution for improving the mother's early initiation of breastfeeding within one hour of delivery.⁴⁰ According to the current study, mothers who started breastfeeding after one hour of birth were 4.4 times more likely to practice pre-lacteal feeding than those mothers who initiated breastfeeding within one hour. This finding is consistent with studies conducted in Nigeria, Pakistan, India,^33–35 and other different studies in Ethiopia.^{9,14,29,31,38} Furthermore, a study conducted in Ethiopia’s Kersa district³¹ found that starting breastfeeding early reduces pre-lacteal feeding by nearly 11 times. Thus, this indicates to us that there is a close relationship between early initiation of breastfeeding and avoiding pre-lacteal feeding.

Conclusions and recommendations

According to our study, 12.1% of women practiced pre-lacteal feeding within three days of delivery, which is higher than in the previous 2016 EDHS. Living in a pastoralist region, experiencing no ANC visit, attending 1-3 ANC visits, home delivery, delivery through C-section, and late initiation of breastfeeding were the determinant factors of pre-lacteal feeding practice among women. The first few days of a newborn’s life are the critical period to their survival. Thus, the government and stakeholders should enhance the continuum of care for pregnant women and continue the 1,000-Day initiative that helps the mother adhere to the optimal breastfeeding practice. The Baby-Friendly Hospital Initiative encourages health facilities to better support breastfeeding, with the goal of providing the best start in life for every baby by creating a healthcare environment that promotes breastfeeding as the norm. As a result, the initiative enables mothers to exclusively breastfeed their children for the first six months. Furthermore, the Initiative provides appropriate counseling services to the mother and her accompanying relative/s regarding the dangers of pre-lacteal feeding and the importance of optimal breastfeeding for the newborn, particularly for women who have had a C-section. Improving the use of institutional delivery would help to reduce pre-lacteal feeding practice. Additionally, strategies to reduce or eliminate pre-lacteal feeding practices will need to take into account Ethiopia’s disadvantaged population and pastoralist regions.

Ethical approval and participants’ consent

The study relied on secondary data, which did not require ethical clearance. The Ethiopian Public Health Institute (EPHI) Institutional Review Board and ICF International’s institutional review board provided ethical approval for the 2019 EMDHS. Respondents were informed about the survey and their random selection for inclusion, and verbal informed consent was obtained from each participant for their participation. Each participant was required to participate in and withdraw from the study voluntarily. During interview and data analysis, participants’ confidentiality was maintained.

Authors’ contributions

GM designed the study, conducted data analysis, and wrote the original paper. The data analysis and write-up sections of the manuscript were primarily supported by FG, AT, and GT. Some of the manuscript section was written by FG. The manuscript was critically reviewed and approved by TG, FG, GT, AT, TT, MG, TS, GG, AD, HT, and HT. All authors contributed to the drafting, the acquisition, analysis, and interpretation of the data, reviewed related articles, agreed on the journal to which the article would be submitted, gave final approval of the version to be published, and agreed to accept responsibility for all aspects of the work. The manuscript was submitted for publication by GM, the corresponding author.