Knowledge and practices about breastfeeding in rural areas of Rajshahi District, Bangladesh: A cross-sectional study [version 1; peer review: 2 approved with reservations, 1 not approved]

Background: Breastfeeding is an important indicator for child health and mortality. The aim of this study was to determine the level of knowledge and practices regarding EBF and its relation to various socio-economic and demographic factors among mothers with at least one child age (6-12 years) in the rural areas of the Rajshahi district in Bangladesh. Methods: A study based at village hospitals was conducted and a semi-structured questionnaire was used. A total of 513 mothers who had at least one child's age (6-12) months from 32 different village hospitals in rural areas of the Rajshahi District, Bangladesh from September to December 2015. The composite index, chi-square test and binary logistic regression model were used in this study. Results: The incidence of EBF good knowledge and practices was 32.0% and 27.9% among mothers with at least one child age (6-12) months. The analysis shows that the age of mothers ≥ 31 years have less knowledge and practice about EBF compared to mothers aged ≤ 30 years. Mothers who are housewives had a higher probability of good knowledge and practice than mothers who were service providers. Nursing mothers at home have less knowledge and practices about EBF than mothers who gave birth in the hospital. Mothers that had a monthly family income of ≤ 6 699 BDT had less knowledge and practices about EBF compared to mothers with a family income of >6 699 BDT. Conclusions: This


Introduction
Exclusive breastfeeding (EBF) is one of the best nutrition practices for child health, growth and nutrition and is an optimal strategy for feeding newborn and young infants 1 .According to WHO and UNICEF, EBF should start within less than one hour of delivery and should continue for up to 6 months of infants' age as it is the only diet and source of fluids for babies at that age 2 .
Children, especially new born babies, are in high danger of malnutrition during the first six months of life when breast milk alone is necessary to meet all nutritious supplies and breastfeeding needs to continue during this time 3 .Good practice of EBF can prevent 13.8% and 11.6% of all deaths among infants aged <2 years and those under 5-years, respectively 4 ; however, a report estimated that in 2012 only 35% of infants were exclusively breastfed globally 5 .EBF, due to its various recognized health welfare for babies, children and their mothers, is a crucial plan to improve public health 6 .Low breastfeeding rates have been found in Canada, as well as other industrialized countries 7 , and EBF for at least 6 months is not a general practice in developed nations, and is even less in developing nations 8 .Usually infant development is measured by nutritional level 9 .
Nearly all Bangladeshi children are breastfed to some extent in the first year of life and many mothers continue to breastfeed up to the second year of a baby's life (91%) 10 .Bangladesh has the highest prevalence of malnourishment in South East Asia with a high percentage of children aged 59 months being underweight 10 .To determine knowledge and practices of newborn nourishment is imperative 11 .
Several studies have been performed to assess the knowledge, perception and practices of breastfeeding among women and to assess the global trends of EBF 12,13 .For instance, previous studies have been conducted in Nigeria about knowledge, attitude and techniques of breastfeeding mothers of under five children 14,15 .In Ethiopia, special concern has been paid to the association between schoolgirls' perception and knowledge about breastfeeding, and knowledge and practice of mothers towards EBF 16 .
Only a few studies have been carried out on EBF, and most of these studies were carried out in developing countries 17,18 .Furthermore, methodological concerns associated with the measurement of knowledge and practices about EBF have not been adequately addressed in earlier studies.The difficulty of judging knowledge lies in its multidimensional aspects; most of studies have been focused on a few indicators.To the best of our knowledge, in Bangladesh this type of study has not been conducted.Therefore, the aim of the present study was to assess the knowledge and practices of EBF among mothers who have at least one child aged 6-12 months in Rajshahi District, Bangladesh.

Study design
A village hospital based study was conducted in the rural area of Rajshahi district, Bangladesh.There are several reasons why we selected mothers who have at least one child aged 6-12 months from different village hospitals in Rajshahi district.Firstly, to the best of our knowledge in this area no studies have been conducted on EBF; secondly, this area is situated in the remote areas of Rajshahi 19 .Most of the sample population included all participants that were living near different village hospitals in Rajshahi district, Bangladesh.

Simple size determination
The following formula has been used for calculating sample size: n= N/ (1+Nd 2 ), where n = required sample size, N= population size (5,123), d = marginal error (0.05) 20 .The formula provided that the minimum sample size was estimated to be 366 for this study.For a better result, we collected data from 513 participants.

Participants
Before sampling, lists of children aged 6-12 months were gathered from the Charghat upazila (sub-district) Health Complex, Rajshahi, from lists used in expanded programmes on immunization.A two-stage purposive sampling approach was chosen to enrol mothers that have at least one child aged 6-12 months from Rajshahi district.In the first stage, out of nine upazila of Rajshahi District, one upazila was purposively selected.In the second stage, purposive sampling was used for the selected sample size.The inclusion criteria of the participants was mothers who have at one child aged 6-12 months and those with no psychological disorders.Exclusion criteria was male parents.The participants asked to be interviewed during routine check-ups.The interviews took place at the participants homes.

Data collection
From September to December 2015, we collected the following data from the mothers for the study: (i) socio-demographic characteristics and (ii) knowledge about EBF using a semistructured questionnaire by face-to-face interviews from the villages in Rajshahi District.The survey questionnaires were drafted in Bangla, the national and mother tongue of Bangladesh and was then for research purpose translated into English (Extended data).Five fully trained and experienced enumerators conducted the interviews.

Outcomes variables
The dependent variable in our study is the level of good knowledge about EBF, which was calculated through nine different questions, namely: i) The respondent's knowledge and practice were scored using a system adopted from earlier studies.A correct reply was given 1 point, while incorrect replies received 0 points [34].

Independent variables
Socio-economic and demographic factors were included as independent variables.Age was classified into two groups: ≤ 30 years and ≥ 31years.Place of delivery was divided into two groups (hospital and home) and occupation was classified into two groups (housewife and service holder).Education was classified based on the formal learning system in Bangladesh: Illiterate and literate.Size of family was categorized as joint (both parents) or single family.Respondent's monthly income was categorized as yes or no to the question: do you earn ≤6,999 Bangladeshi Taka (BDT)?-(≤6,999 BDT = yes; ≥7,000 BDT = no).

Statistical analyses
Statistical Package for Social Science (SPSS) version 22 IBM was used to analyse the data.Descriptive analyses were conducted to ascertain the socio-economic and demographic variables, and the good knowledge and practice scores.Demographic differences regarding good knowledge and practices of EBF were assessed by χ 2 analysis significance, and all analyses was set at p<0.05.Completely adjusted models were used to analyse each binary outcome variable.All variables were inputted into binary logistics regression models.The adjusted odds ratio (AOR) was observed to assess the strength of the associations, and 95% confidence intervals (Cis) for significance test were used.
The knowledge index was calculated through the sums of binary input variables, where the highest and lowest values were selected for each underlying pointer.To determine the knowledge pertaining to breastfeeding, ten questions about the knowledge of breastfeeding were provided.The question was answered CORRECT or INCORRECT.A score of 1 was given for a correct answer and 0 for the incorrect answer.The scores varied from 0-9 points and were classified into two levels, as follows: Bloom's cut off point, 60%-80%.The items were all assessed using a zero-one indicator (dummy variables).These variables were given a value of zero (low knowledge less than 6 points) for 'No' (Bloom's cut off point less than 59%), and a value of one (high knowledge more than or equal to 6 points) for 'Yes' (Bloom's cut off point 60% -80% or high).The enactment of individually pointer was articulated using a unit-free index between 0 and 1 in accordance with the structure technique of the Human Development Index 21 .

Ethics approval and consent to participate
This study was approved by the Department of Population Science and HRD, University of Rajshahi, Bangladesh (Ref: 2658/89, Date: 22/12/2014).Written informed consent was obtained from participants before data collection.

Results
A total of 513 mothers were involved in this study.From the total sample population, approximately 61% were ≤30 years of age, 60% of deliveries were at hospital and 61% respondents were housewives.Regarding education, 27.5% were illiterate, 19.1% were primary educated and the remaining 53.4% had secondary or higher level of education.A total of 79.5% were from a joint family, and a major portion of respondent's (59.8 %) had a monthly family income <6,999 BDT.
There was a good level of knowledge and practice of EBF among the mothers that participated in this study.Table 1 and Table 2 show the socio-economic and demographic factors associated with good knowledge and practice.From the total sample population, 32% mothers had a good level of knowledge and 27.9% mothers had a good level of practice about EBF, which was statistically significant (p<0.05) for all variables apart from education.

Discussion
This study surveyed the knowledge and practice of EBF among mothers in rural area of Rajshahi district, Bangladesh.There are two major findings for this study.First, poor knowledge and practice of EBF was seen in 32.0% and 27.9% of mothers.Second, mothers that had good knowledge and practice about EBF were aged ≤30 years, were housewives, had a hospital delivery, were joint family members and had ≤6,999 BDT monthly family income.
The study assumed that most of the mothers would have good knowledge and practice of EBF; however, the study demonstrated that a small percentage of mothers in this area were assessed as having a good level of knowledge and practice of EBF.This study therefore highlights the need for EBF health education programs to educate mothers.
Until now, according to the best of our knowledge this type of study has not been performed in Bangladesh, but similar studies have been conducted in different populations 22 .The study found that, middle aged mothers (≤30 years) had low knowledge and practices as compared with older respondents (>31 years) and similar results have been found in other countries 23 .The present study found that hospital delivery respondents had low knowledge and practices as compared with their counterpart, which is consistent with a previous study in Ethiopia 24 .An extra assumption was that most of the service holder mothers, and those with secondary and higher level of education would have a better knowledge and practice than housewives or those who did not have a high level of education; however, we found that housewives had good knowledge and practices compared with those that were service holders.This study result is consistent with previous other studies 25,26 .
Those mothers that had joint families had a good of knowledge and practice compared with single mothers.This may be because those mothers in joint families can share their knowledge with other family members.The study also found that mothers from families with ≤6,999 BDT monthly income had good knowledge and practice.
As a final point, the idea of good knowledge and practices of EBF had various definitions.Therefore it is challenging to measure, particularly using the questionnaire used in the present study.However, this study measures knowledge and practice through a lot of indicators, which were seen in a previous study 27 .
This study had a few limitations.Firstly, it was a village based study and people are busy.Secondly, there are 64 districts and 491 sub-districts (upazilas) in Bangladesh, and in this study we considered only one district and one upazila; therefore, more upazilas should be looked.

Conclusions
This study found that there are huge knowledge and practice gaps regarding EBF among mothers that have at least one child aged 6-12 months.As malnutrition will be decreased if EBF is widely established, this study suggests that EPF related education and interventions could play an important role to increase the level of knowledge and practice concerning EBF among this population of mothers.Health policy makers of Bangladesh should consider performing a study with a larger sample size so that further information can be obtained regarding knowledge and practice of EBF in Bangladesh.
This project contains the following extended data: -Questionnaire in Bangla and English.

Introduction:
In this section, the statement "To the best of our knowledge, in Bangladesh this type of study has not been conducted" is not exactly correct.Because I had found similar studies conducted in Bangladesh when I searched on Pudmed.Such as two articles, "Exclusive breastfeeding practice during first six months of an infant's life in Bangladesh: a country based cross-sectional study" (https://doi.org/10.1186/s12887-018-1076-0)I suggest the author reported more findings from previous studies and addressed your novelty in this manuscript.

Methods:
In this section, I agree with suggestions from Felix Emeka Anyiam.Additionally, there was a minor error."ten questions about the knowledge of breastfeeding were provided".But nine questions were mentioned above.Please check it.

1.
The statement "There was a good level of knowledge and practice of EBF 2.
Among the mothers that participated in this study", but I thought it is not good enough (32% vs.27.9%).And you mentioned in the discussion "poor knowledge and practice of EBF was seen".Is it opposite to results?Please check it.
For table 3 and table 4, I have different explanations.For table 3, my interpretations were mothers aged ≥31years, gave birth at home and had ≥7,000 BDT monthly family income were less likely to have good knowledge of EBF compared to their counterparts (p<0.05).Mothers that were literate, service holder and had single families were more likely to have good knowledge of EBF compared to their counterparts (p<0.05).For table 4, my interpretations were mothers aged ≥31 years, gave birth at home, had single families and had ≥7,000 BDT monthly family income were less likely to have good practices of EBF compared to their counterparts (p<0.05).Mothers that were literate, service holder were more likely to have good practices of EBF compared to their counterparts (p<0.05).

1.
Because in my opinion, If OR>1, 95% CI did not include 1 and p<0.05, the dependent variable was a risky factor.The risk for the dependent variable (which was label as 1) had more times of risks than the dependent variable (which was label as 0).If OR<1, 95% CI did not include 1 and p<0.05, the dependent variable was a protective factor.Please see more information of logistic regression interpretation.Reviewer Expertise: human nutrition, food safety, nutrition and health We confirm that we have read this submission and believe that we have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however we have significant reservations, as outlined above.I have the following comments: The authors' claim that this is the first study of its sort, is unjustified.Several studies have been carried by researchers independently and also based on data obtained during Bangladesh health and demographic survey. 1.
In the Result section, the authors mentioned: "The incidence of EBF good knowledge and practices was 32.0% and 27.9% among mothers with at least one child age (6-12) months."I believe this value here is prevalence and not incidence as this is a cross sectional study, as incidence is a measure of the occurrence of new cases of disease (or some other outcome) during a span of time.

2.
In the Result section, the authors mentioned: "Mothers that had a monthly family income of ≤ 6 699 BDT had less knowledge and practices about EBF compared to mothers with a family income of >6 699 BDT."I think from the results in Tables 1 & 2, it's more (or good which is the right term to use) Knowledge and Practice and not less for both.

Introduction
In text Referencing: The information in Reference 8, "EBF for at least 6 months is not a general practice in developed nations, and is even less in developing nations" is too old (1999) and may not be the true state of things in the present time.A reference not older than 10 years should be sought and is recommended.

1.
In text Referencing: The information in Reference 10, "Nearly all Bangladeshi children are breastfed to some extent in the first year of life and many mothers continue to breastfeed up to the second year of a baby's life (91%)" is from one study and not suitable for this sort of generalization.A systematic review would have been more appropriate.

2.
In text Referencing: Also the same reference 10 stated something contrary from the previous sentence above: "Bangladesh has the highest prevalence of malnourished in South East Asia with a high percentage of children aged 59 months being underweight ."I am not sure which to consider appropriate.

3.
The authors stated in the last paragraph of the introduction: "Only a few studies have been carried out on EBF, and most of these studies were carried out in developing countries."Although my own personal search showed several studies.Authors should use a more rigorous search strategy.

4.
The authors stated in the last paragraph of the introduction: "Furthermore, methodological concerns associated with the measurement of knowledge and practices about EBF have not been adequately addressed in earlier studies."If this is so, then the studies applicable should be stated.

5.
The authors stated in the last paragraph of the introduction: "The difficulty of judging knowledge lies in its multidimensional aspects; most of studies have been focused on a few indicators."I understand accessing knowledge of any kind requires a multidimensional approach but I do not agree that it's a difficult process.Please rephrase sentence.

6.
On the last paragraph of the introduction, the authors stated, "…most of studies have been focused on a few indicators."Should read "most of the studies have been focused on a few indicators."

7.
The statement: "To the best of our knowledge, in Bangladesh this type of study has not been conducted" is not completely accurate as my personal search found several studies.

Study design
Study design was not mentioned.Although from the title of the study, it was clear that this is a cross-sectional study but it was not mentioned in the right place.What was said here was: "A village hospital based study…" which is not a study design.Please include the study design in this section.The benefits of publishing with F1000Research: Your article is published within days, with no editorial bias • You can publish traditional articles, null/negative results, case reports, data notes and more • The peer review process is transparent and collaborative • Your article is indexed in PubMed after passing peer review • Dedicated customer support at every stage • For pre-submission enquiries, contact research@f1000.com breastfeeding among mothers in rural areas of Rajshahi district in Bangladesh: A community clinic based study.PLoS One.2020; 15 (5): e0232027 PubMed Abstract | Publisher Full TextIs the work clearly and accurately presented and does it cite the current literature?PartlyIs the study design appropriate and is the work technically sound?PartlyAre sufficient details of methods and analysis provided to allow replication by others?PartlyIf applicable, is the statistical analysis and its interpretation appropriate?PartlyAre all the source data underlying the results available to ensure full reproducibility?YesAre the conclusions drawn adequately supported by the results?YesCompeting Interests: No competing interests were disclosed.

Reviewer Report 16
December 2019 https://doi.org/10.5256/f1000research.22133.r57778© 2019 Azad K.This is an open access peer review report distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.Kishwar Azad 1 Diabetic Association of Bangladesh, Dhaka, Bangladesh 2 Ibrahim Medical College, Dhaka, Bangladesh The article titled, 'Knowledge and practices about breastfeeding in rural areas of Rajshahi District, Bangladesh': A cross sectional study, examines the knowledge and practices regarding exclusive breastfeeding among mothers with at least one child aged 6-12 months.
M, Sayem A, Karim R, Islam N, et al.: Assessment of knowledge regarding tuberculosis among non-medical university students in Bangladesh: a cross-sectional study.BMC Public Health.2015; 15: 716 PubMed Abstract | Publisher Full Text Is the work clearly and accurately presented and does it cite the current literature?Partly Is the study design appropriate and is the work technically sound?Partly Are sufficient details of methods and analysis provided to allow replication by others?Partly If applicable, is the statistical analysis and its interpretation appropriate?Yes Are all the source data underlying the results available to ensure full reproducibility?Partly Are the conclusions drawn adequately supported by the results?Yes Competing Interests: No competing interests were disclosed.Reviewer Expertise: Public Health, Population Health, Global Health, Epidemiological Research, Biostatistics, Open Research Data, Open Science, Data Science, Non-communicable diseases, Maternal and Child Health, Vulnerable Populations, Population at Risk, Reproductive Health, Data Management, Community-Based Research, HIV/AIDS Prevention, TB Prevention, Health Management and Health Promotion I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above.

Table 4 . Effects of socio-economic and demographic variables associated with practice of exclusive breastfeeding among mothers in Bangladesh with at least one child aged 6-12 months. Explanatory variables Adjusted odds ratio (AOR) 95% CI for AOR P-value Lower Upper Age (years)
R reference category

Table 3 . Effects of socio-economic and demographic variables associated with knowledge of exclusive breastfeeding among mothers in Bangladesh with at least one child aged 6-12 months.
R reference category Knowledge and practices of exclusive breastfeeding among mothers in rural areas of Rajshahi district in Bangladesh: A community clinic based study" (https://doi.org/10.1371/journal.pone.0232027)2.It is published on May 2020.The present study was similar with it, including the same study design, sample size and analysis.
1.It is the Bangladesh Demographic and Health Survey (BDHS-2014) which collected data from 17,863 Bangladeshi married women in reproductive age from the entire country.1. "