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To assess the Initiation of breast milk expression and associated factors among mothers of preterm neonates admitted to the Neonatal intensive care unit, at Amhara region comprehensive specialized Hospitals, Ethiopia 2023.

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To determine the Initiation of breast milk expression among mothers of preterm neonates admitted to the Neonatal intensive care unit, at Amhara region comprehensive specialized Hospitals, Ethiopia 2023.

A multicenter institutional-based cross-sectional study was conducted from April 15 to May 15, 2023, in the Amhara region. The study was conducted in eight comprehensive specialized hospitals (University of Gondar, Felege-Hiwot, Tibebe-Ghion, Debre-Markos, Dessie, Deberetabor, Debreibrhan, and Woldya). Those hospitals have special units, like the NICU, and the major services in the NICU include general neonatal care services, routine prescription of a complete blood count, blood exchange transfusion, phototherapy, and ventilation support.

Source population

The source population was all mothers with their preterm neonates who were admitted to the NICU of the Amhara Region Comprehensive Specialized Hospitals.

Study population

The study population was all mothers with their preterm neonates who were admitted to the NICU at Amhara Region Comprehensive Specialized Hospitals during the study period.

Inclusion criteria

All mothers with their preterm neonates who were admitted to the NICU of the Amhara Region Comprehensive Specialized Hospitals during the study period.

Exclusion criteria

The presence of medical contraindications for breastfeeding, neonates keeping NPO, and neonates with incomplete charts during the data collection period was excluded from the study.

The sample size was determined using the single population proportion formula by considering the following assumptions: p = 50% (proportion of mothers with initiation of breast milk expression), 95% confidence interval (Z = 1.96), 5% level of significance, and 5% margin of error (d = 0.05). n = ( Z ) 2 ∗ ( p ∗ 1 − p ) / d 2 n = ( Z ) 2 ∗ ( p ∗ 1 − p ) / d 2 , n = ( 1.96 ) 2 ∗ 0.5 ( 1 − 0.5 ) / ( 0.05 ) 2 = 384

By adding 10% non-respondents (by considering refusal and incomplete charts) the final sample size was estimated to be 422. To ensure the adequacy of sample size, Epi-info version 7.2.3 is used to calculate sample size for factors associated with the initiation of breast milk expression by using 2 factors Gestational age and getting instruction from NICU staff. By using frequency of non-exposed groups and depends on their AOR.

As compared with the sample size above the sample size for this study is the largest one in the first objective single population proportion formula which is 422. The allocation of the sample to each hospital was made based on the average number of neonate admissions per month. The overall sample was taken proportionally from each hospital, and a systematic random sampling technique (sampling interval ≈ 2) was used to select the sample participants.

Outcome variable: Initiation of breast milk expression was the outcome variable; it is the time when mothers began expressing milk from their breasts, which was measured by asking the mother when she started milk expression.

Socio-demographic characteristics of the mother: 5 factors (maternal age, educational status, occupational status, marital status and residence).

Obstetric and maternal characteristics: 11 factors (Knowing the importance of breast milk for preterm neonate, getting instruction to express breast milk from NICU staff within 6 hours after delivery, Pregnancy-related complications, knowing the benefits of colostrum, Know the importance of mother’s milk over other (powder, cow) milk, mode of delivery, parity, ANC follow-up, place of delivery, Previous NICU experience with preterm admission and Previous milk expression experience for the preterm neonate).

Neonatal characteristics: 8 factors (GA, gender, birth weight, postnatal first milk-feeding time, method of feeding, can able to suck a neonate, health status of a neonate and post-natal age).

Psychological factors: 4 factors (Support from family members, separation from their premature infants and worried about the amount of milk and kangaroo mother care) were the independent variables.

Family support is any support given: food, support in daily living activities, starting from the time she gives birth (husband, mother, sister). ^{1, 6}

LBW: (low birth weight) <2500 mg, VLBW: (very low birth weight) 1000 – 1500 gm, ^{1, 35}

Gestational age: this is the time counted in weeks from the first day of the woman’s last menstrual period to the date of delivery. ^{1, 36}

Preterm birth: It is the birth of a baby <37 weeks and >28 weeks GA. ^{1, 35}

Initiation of breast milk expression: It is time for the mother to begin expressing breast milk, and the mother can begin expressing breast milk usually immediately following childbirth. ^{3, 35}

Early initiation of breast milk expression: Expression of breast Early within 6 hours of birth ^{6– 8}

Late initiation of breast milk expression: expression of breast milk > 6 hrs of delivery. ^{6, 7}

Stable conditions where a neonate has stable vital signs. ³⁷

Fair Vital signs are stable and within normal limits. the neonate is conscious but may be uncomfortable and the neonate needs regular follow-up. ³⁷

Critical Vital signs are unstable and not within normal limits. the neonate may be unconscious. Indicators are unfavorable and the neonate needs strict follow-up. ³⁷

Early neonatal period: this is a period from birth to 7 completed days of life. ¹

Late neonatal period: A period from 8 to 28 completed days of life. ¹

Early preterm: gestational age < 32 weeks and > 28 weeks, Moderate preterm: gestational age 32 – 34 weeks, Late preterm: >36 weeks. ^{1, 38}

Incomplete chart: Charts with one of the following factors are missed (gestational age, birth weight, feeding time and neonatal age).

The data were collected using interviewer-administered and neonate chart review through structured and validated questionnaires that were adapted from a questionnaire developed from previous studies. ^{6, 19, 24– 26, 30, 31, 34, 39} To ensure consistency and accuracy, the data collection instrument was written in English, translated into the local language (Amharic) by a language expert, and then back into English. A 5% ²¹ pretest was conducted. During pretesting the tool was checked for its consistency. The internal consistency was checked by computing Cronbach’s α with the value of 0.82% from the pretest data. Onsite training was given to data collectors and supervisors before the beginning of data collection. The data was collected by nurses who have previous experience in the NICU and data collection. The completeness of the collected data was checked onsite daily during data collection and received prompt feedback from the supervisor and the principal investigator. All completed data collection forms were examined for completeness and consistency during data management, storage, cleaning, and analysis. Before data collection assent was obtained from the mother then, written consent was obtained after explaining all the purpose, benefits and confidentiality of the information.

The collected data were entered and coded into Epi-Data version 4.6.0.2 and exported into Stata 16.0 software for analysis. Descriptive statistics were carried out using the mean, frequency, percentage, tables, and figures to present the findings. A box plot was used to check the normality of the continuous data. The outcome variable was dichotomized and coded as 0 and 1, representing those late in initiation of breast milk expression and early in initiation of breast milk expression, respectively. The data was checked for consistency. Descriptive statistics were used to identify the distributions of socio-demographic characteristics among study respondents. Frequencies and cross-tabulations were computed before regression analysis. Multicollinearity was checked by using variance inflation factors (VIF 1.02–1.57, mean VIF = 1.20), and the model goodness of fit test was checked by Hosmer and Lem show goodness of fit tests (p = 0.63). A bivariable logistic regression was conducted to see the relation between the dependent and independent variables of initiation of breast milk expression using a p-value < 0.25. Multivariable logistic regressions at p-value < 0.05 with a 95% confidence interval of the odds ratio were used to determine a statistically significant association.

Among the study respondents, the age range of respondents was 16–42, and the mean age was 28.86 ± 6.77 SD. More than half of the 245 (61.10%) respondents lived in urban areas. Regarding marital status, 338 (84.29%) respondents were married.

Out of 401 respondents, 236 (58.85%) were Multi para. And 347 (85.79%) have ANC follow-ups; 119 (29.68%) of them have had 4 or more visits. Regarding pregnancy complications, 150 (37.41%) have pregnancy complications. 289 (72.07%) mothers knew the importance of mother’s milk over other (powder, cow) milk.

Among 401 neonates 217 (54.11%) were female and 184 (45.89%) were male neonates. Regarding birth weight, there were 249 (62.09%) LBWT and 152 (37.91%) VLBWT, and the mean birth weight of neonates was 1557.73 with ± 303.23 SD, and the minimum and maximum birth weights were 1000 g and 2200 g, respectively.

Psychological factors Out of 401 participants, 236 (58.85%) got family support during breast milk expression and 109 (27.18%) are worried about the amount of milk to express milk the first time.

Out of 401 participants, 340 (84.79%) with [95% CI (80.91, 87.99)] were late initiation of breast milk expression (expressed after 6 hours of delivery) and 15.21% (61) with [95% CI (12.00,19.08)] were early initiation of breast milk expression (expressed within 6 hours of delivery).

On bivariable analysis, eleven (maternal age, get instruction to express breast milk within 6 hours of delivery, from NICU staff, Birth weight, Gestational Age, method of feeding, can able to suck a neonate, postnatal age, know the benefit of colostrum, know the benefit of mother’s milk for preterm neonate, family support and health condition of neonates) variables that have a p-value less than 0.25 was taken as a candidate for multivariable logistic regression analysis. In multivariable logistic regression analysis, mothers who did not get instruction within the first 6 hours after delivery, mothers who did not know the importance of mother’s milk for preterm neonates, mothers who did not get family support, and GA < 32 weeks had p-value < 0.05 with a 95% confidence interval of the odds ratio were the results express factors that negatively impact breast milk expression initiation. Respondents (neonates) with GA < 32 weeks were 3.59 times late to initiate breast milk expression compared to GA > 34 weeks (AOR = 3.59; 95% CI: 1.21, 10.61). The other factor identified was that respondents who did not get instruction within the first 6 hours of delivery to express milk from NICU staff were 2.48 times late to initiate breast milk expression as compared with those who got instruction within the first 6 hours of delivery (AOR = 2.48; 95% CI: 1.06, 5.79). Similarly, respondents who did not get family support were 2.19 times late to initiate breast milk expression as compared with those who got family support (AOR = 2.19; 95% CI: 1.10, 4.36). Finally, respondents who do not know the importance of mother’s milk for preterm neonates were 2.36 times late to initiate breast milk expression as compared with those who know the importance of mother’s milk for preterm neonates (AOR = 2.36; 95% CI: 1.24, 4.47).

Due to the cross-sectional nature of the study, it is difficult to determine the association between outcome and independent variable.