Assessment of knowledge attitude and practice of mothers about exclusive breast feeding in

Butajira Town SNNPR Ethiopia

By

Misker Mulugeta

Advisor Name Ato ESHETU GIRMA (Bsc,MPH/Assistant professor)

A Research Proposal submitted to the department of health Education and Behavioral

sciencesofficer Jimma University Health Facility for the partial fulfillment of the requirement
for the bachelor of Sciences Degree in Health Education and PromotionPublic Health

Assessment of knowledge attitude and practice of mothers about exclusive breast feeding in
Butajira Town SNNPR Ethiopia

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 By

Misker Mulugeta

Advisor Name Ato ESHETU GIRMA

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 Abstract

Background: - EBF practices are feasible and cost effective way of preventing and decreasing
disease and infant death. Even though the benefit of EBF is every wide the coverage is low. Due
to that the prevalence of malnutrition increases in many countries including Ethiopia.

Objective: - the aim of the study was to asses knowledge, attitude and practice of mother
towards EBF in butajira hospital butajira town SNNPR Ethiopia

Methods: - institutional based discriptivetributive cross- sectional study was conducted in

butajira hospital

The data was collected with structured questions and protested interviewerd administered
quotationner by ted data collectors. The obtain data cleared checked and analyzed by the data
collectors

Result :- 62.5 mothers know about EBF and 37.95% do not know about EBF almost 2/3 (64.4%)
mothers replay that the size breast and milk production has no relationship among the
interviewed mothers 67.59 used to give i.e breast milk for the first time 30.75% used to give
water and other fluid and 49.61% initiateed breast feed after an hour

Conclusion and recommendation: 62.5% of mothers know what EBF mean I recommend that
mothers encourage and supported during MCH service about knowledge of EBF

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 TABLE OF CONTENT

 
Contents                                                                                 pages
Abstract ........................................................................................... i
Acknowledgement............................................................................ ii
Table of contents .............................................................................. iii
List of tables ..................................................................................... IV
List of figures……………………………………………………………..v

CHAPTER ONE: INTRODUCTION

1.1 back ground information ............................................................ 6
1.2 statement of the problem ........................................................... 7
1.3 Significance of the study ............................................................. 8

CHAPTER TWO: LITERATURE REVIEW ........................................ 8

CHAPTER THREE: OBJECTIVES ..................................................... 31
3.1 General objective ....................................................................... 31
3.2 Specific objective ........................................................................ 31

CHAPTER FOUR: METHODOLOGY ............................................... 32

4.1 study area .................................................................................. 32
4.2 study design and period .............................................................. 32
4.3 population .................................................................................. 32
4.3.1 Source population ................................................................... 32
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4.3.2 Study population ..................................................................... 32
4.4 sample size.................................................................................. 32
4.5 sampling procedure (technique).................................................. 33
4.6 study variables............................................................................ 33
4.6.1 Dependent variables ................................................................ 33
4.6.2 Independent variables ............................................................. 33
4.7 Operational definitions ............................................................... 33
4.8 Data collection ............................................................................ 34
4.8.1 Instrument .............................................................................. 34
4.8.2 Data collection procedure ........................................................ 34
4.9 Validity and reliability ................................................................. 34
4.10 Data processing and analysis ..................................................... 34
4.11 Ethical consideration ................................................................. 34
4.12 dissemination of result  ............................................................. 34
CHAPTER FIVE: WORK PLAN AND BUDGET PROPOSAL     
Work plan……………………………………………………………… 34
BUDGET
PROPOSAL………………………………………………………………….. 35
REFERENCES ..................................................................................... 36

Questioner………………………………………………………………….25

Dummy table ……………………………………………………………26

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Table -1 distribution mother by their age visit MCH service in butajira hospital 2011

Table -2 distribution mothers by their religion visit MCH service in butajira hospital 2011

Table -3 distribution mother by their education level who visit MCH service butajira hospital
2011

Table -4 distribution of mother by their occupational states who visit MCH service in buatajira
hospital 2011

Table -5 differences in time limitation of BF mothers who visit MCH service in butajira hospital
2011

Table -6 distribution of mothers by their socio demographic characteristics who follow MCH
service in butajira hospital 2011

Table -7 summery of question and respond on knowledge of mothers towards EBF who follow
MCH service in butajira hospital 2011

Table -8 summery question and response on attitude of mothers to ward EBF who follow MCH
service in butajira hospital

Table -9 summery of quoin respond on practice of mothers towards EBF who follow MCH
service in butaira hospital

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List of figure

Figure -1 marital status of women that follow MCH service in butajira hospital

Figure -2 age distribution of children whose age is lease than 24month

Figure -3 disruptions mother’s knowledge of the duration EBF in Butajira hospital

Figure -4 showing practice of mothers when they away from their home Butajira hospital

Figure -5 showing practice mothers who give total breast feeding Butajira hospital

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List of abbreviation

ANC - antenatal care a

ARTI – acute respiratory tract infection

Bf – breast feeding

CF – complimentary feeding

DHS – demographic health survey

EBF – exclusive breast feeding

MCH – mother and child health

SNNPR – southern nation nationalitiesst and peoples region

TBA – traditional birthreast attendant

UNICEF – united nation international child and educational fund

WHO- world health organization

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 Acknowledgment

First of all would like to acknowledge my advisor Ato ESHETU GIRMA for his guidance.

Secondary I pass deepest application to BHL MCH states specially

Sister Almenshe Denbel head of MCH. Giving permit ion to me to conduct this study.

More over I would like to thank all my friends. Who haveare participated in this study and also I
would like my family.

Too many grammatical and editorial problems!

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 Chapter one

Introduction

1. Back ground

Globally malnutrition is found to be over 800millioen children each year more than 10million
children 8under 5 years of age die most from preventable causes with the vast majority in pore
countries for more than 50% of this death are either direct or indirect attribute to malnutrition

The commonest cause of malnutrition are sub optimal infant and young children feeding such us
breast feeding practice optimal feedings infant and young children means EBF from birth to
about 6 month followed by introduction to of complimentary feeding drown from local diet at
about 6 month

EBF are feasible cost effective way of preventing and decreasing disease and infant death.
Even if the benefit of EBF is very wide its prevalence and duration decrease in many countries
including Ethiopia. The nationalities prevalence of EBF is 49%.

SNNPR is one the regional state in the country it has total populate14,502,00 of this gurage zone
is found in SNNPR and has total population of 1,690,745

The zone has 13 worda and 2 administration town butajira Is one of the 2 administration
town which is located at 8.8 north latitude and 38.22 east longitudinal with an altitude of
between 1850-2100 meter above the sea level. In addition, the climate constitution of town is
woynadga with an annul ale l rain fall of 100-1300 mm range and average environmental
temperature of 210c soil type are sandy clay and loam. The total population of butajira town is
35357. Here several ethnic grow living together gurage is the predominant ethnic group
followed by Siliti and Amhara the commonest language spoken is guragigna and most are
Muslim religion.

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 In the town have government institutions, one hospital and one health center and one non
govern mental hospital.

Where are your references? Please read your research methods module on how to write
references!

2. Statement of the problem

Breast feeding has numerous demographic .social and economical effects. It affects the health
and nutritional status of both the mother and child. Breastfeeding for the first2 years protects the
young child from infection ;provide an ideal source of nutrients ;it is cost effective and safe from
of feeding ; foster mother. Child bonding and lowers the risk of early child hood death(I)

UNICEF and WHO recommended that children be exclusively breastfeeding during the first six
months of life and those children more than six months be given solid or semisolid
complementary food. EBF is recommended because breast milk is an contaminated and contains
all nutrients and antibodies necessary for children in six months of life(1).

Ideally infants should exclusively breast feed just after birth up to six months of life .
However, in some countries like India , Pakistan, Nigeria , Haiti and Cameron grater than 40% of
children are put on breast later than the second days(2). Thus they are deprived the beneficial of
co lustrum and there is a probability to receive pre- lateral liquid.
Early supplementation during the first six months of the life are important risk factors for child
hood morbidity and mortality.

Early supplementation during the first six months of life are important risk factor for child hood
morbidity and mortality. Especially resulting from diarrheal disease , ARTI, in developing
countries(3) : foe example EBF infant are 14 times less likely to die form diarrhea : compared
with partially breast feed infant(4).

Population behavior related to the problems have many implication .Some think that there is
areolation ship between size of the breast and milk production .Others related breast size and
milk production ;others related breast- feeding with pain and cancer , even it in recent years

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investigators realize that breast feed is possible means of preventing cancer There are also wrong
perception like breast ,feeding is not nutrition and it will give had figure to the mothers (7)

Acceding to DHS. 2005 the major factors that influence exclusive breast –feeding are place of
delivery at health institution .Education level is also another factor that highly education (5)

Even it exclusive breast –feeding is important for healthy growth of infant ,there is no research
conducted on knowledge and altitude of mothers and factors that leads to low practice of
exclusive breast- feeding and attitude of mothers and factors that leads to low practice of
exclusive breast –feeding in Butajira Hospital
3 .SIGNIFICANCE OF THE STUDY

Now a days there is a high rate of mortality and morbidity related to an proper EBF . It is very
important to assets KAP of mothers to wards EBF as they got major responsibility for their
children appropriate growth .So densiting and addressing the major influencing factors and
problem will help to alleviate the high rate morbidity and mortality related to low EBF.

CHAPTER 2

LITRATURE REVIEW

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Human milk has composition that is tailored to the requirements of small infant Breast –feeding
is always fresh pure ,readymade requiring no preparation .It is at the right temperature
uncontaminated and aseptic(1)
Breast milk also contain adequate mineral and nutrients , immune components cellular elements
and anti –parasitic protection(3)

The commonest cause of malnutrition are sub-optimal intent and young child feeding such as
breast feeding practice and 24% intent of death are due to poor breast feeding (6) The
commonest causes of death according to WHO/UNI CEF recommendation are gastrointestinal
disease like diarrhea and infections like ART(1)

Optimal feeding of infant and young children means EBF from birth to about six months
followed by introduction of complementary feeding down from local diet at about six months(8)
Most infants start breast-feeding shortly after almost always with in 4-6 hours .More than two in
three are breast-feeding with in one hour of birth (69%) and 86% with in one day of birth .29%
children were given pre-lacteal fluid during the first three days of life.45% of children were
given first breast early has increased in the five years. The increased being more pronounced for
children breast-feeding with in one hour(5)

Optimal breast –feeding practices from 0-6 moths include initiating breast feeding with in on
hour of birth ; do not give any pre-lacteal feed such as water ,other liquids and ritual foods;
establish good breast feed skills that is proper positioning ,attachment and effective feeding ;EBF
for the first six months without fluids and other liquids ; frequent and on demand breast feeding
every 2-3 hours; after second breast after employing the first breast; mother continues breast
feeding more often when the infant is sick a mother who will be away from her infant for an
expended period express her breast milk and care giver feeds the infant with cup(8)

The advantage of breast-feeding are ; it the best natural food babies as it contains sufficient
amount and right mixture fat ,sugars, proteins, minerals and vitamins for growing babies easy to
digest and nutrients are well absorbed .It contains enough fluid for the first six months of life.
(breast milk90% water); It protects the baby from disease against the germs that cause diarrheal

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disease respiratory infection and other infections. It is almost always clean and available 24
hours of a day and any thing and protects against all edigies because it contains substance that
could provoke allergies relation. It creates bounding between mother and baby that leads to
better psycho-motor and social development. Because of the above development ,breast milk
promote normal growth and development of the babies (8)

Feeding recommendation for infant HIV mothers in developing countries remain

controversial .As HIV can be transmitted on the infant by breast feeding the recommendation or
WHO is that when replacement milk is acceptable feasible affordable sustainable and safe
avoidance of all breast feeding by HIV infected mothers is recommended other wise EBF is
recommended during the first month of life (1)

There is virtually no absolute contraindication but there are some situations where breast feeding
may be avoided such as in mother with chronic disease like TB ,Leprosy ,AIDS, mothers
severally addicted to alcohol and heavy dose of some –drug psychosis local breast absess or
crackled nipple .Infant gross pre-maturity of the baby or other conditions in which the new born
can not suck ,breast milk jaundice (1)

I would like to attach aresearch of breast feeding practice in Sri Lanka

Breastfeeding practices in a public health field practice area in Sri

Lanka: a survival analysis
Suneth B Agampodi1*, Thilini C Agampodi1 and Udage Kankanamge D
Piyaseeli2

* Corresponding author: Suneth B Agampodi

sunethagampodi@yahoo.com

Author Affiliations
1
Additional Medical Officer of Health, MOH office, Beruwala, Sri Lanka

2
Director, National Institute of Health Sciences, Nagoda Road, Kalutara,
Sri Lanka

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For all author emails, please log on.

International Breastfeeding Journal 2007, 2:13 doi:10.1186/1746-4358-2-

13

The electronic version of this article is the complete one and can be found
online at: http://www.internationalbreastfeedingjournal.com/content/2/1/13

Received: 1 June 2007

Accepted: 11 October 2007
Published: 11 October 2007

© 2007 Agampodi et al; licensee BioMed Central Ltd.

This is an Open Access article distributed under the terms of the Creative
Commons Attribution License (http://creativecommons.org/licenses/by/2.0),
which permits unrestricted use, distribution, and reproduction in any
medium, provided the original work is properly cited.

Abstract

Background

Exclusive breastfeeding up to the completion of the sixth month of age is the

national infant feeding recommendation for Sri Lanka. The objective of the
present study was to collect data on exclusive breastfeeding up to six
months and to describe the association between exclusive breastfeeding and
selected socio-demographic factors.

Methods

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A clinic based cross-sectional study was conducted in the Medical Officer of
Health area, Beruwala, Sri Lanka in June 2006. Mothers with infants aged 4
to 12 months, attending the 19 child welfare clinics in the area were included
in the study. Infants with specific feeding problems (cleft lip and palate and
primary lactose intolerance) were excluded. Cluster sampling technique was
used and consecutive infants fulfilling the inclusion criteria were enrolled. A
total of 219 mothers participated in the study. The statistical tests used were
survival analysis (Kaplan-Meier survival curves and Cox proportional Hazard
model).

Results

All 219 mothers had initiated breastfeeding. The median duration of

exclusive breastfeeding was four months (95% CI 3.75, 4.25). The rates of
exclusive breastfeeding at 4 and 6 months were 61.6% (135/219) and
15.5% (24/155) respectively. Bivariate analysis showed that the Muslim
ethnicity (p = 0.004), lower levels of parental education (p < 0.001) and
being an unemployed mother (p = 0.021) were important associations of
early cessation of exclusive breastfeeding. At the time of the study, 62%
(135/219) of infants were receiving feeds via a bottle and 23% (51/219)
were receiving infant formula. Muslim ethnicity was significantly associated
with bottle and formula feeding (p < 0.001). Bottle feeding was also
significantly higher among mothers with a low level of education and among
employed mothers.

Conclusion

The rate of breastfeeding initiation and exclusive breastfeeding up to the

fourth month is very high in Medical Officer of Health area, Beruwala, Sri

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Lanka. However exclusive breastfeeding up to six months is still low and the
prevalence of inappropriate feeding practices is high.

Background

The single most cost effective intervention to reduce infant mortality in

developing countries would be the promotion of exclusive breastfeeding. The
estimated reduction of infant mortality by promoting exclusive breastfeeding
is 13% [1]. Non-exclusive breastfeeding rather than exclusive breastfeeding
can increase the risk of dying due to diarrhea and pneumonia among 0–5
month old infants by more than two-fold [2]. Benefits of exclusive
breastfeeding up to six months duration have been studied all over the world
and there are enormous amount of evidence to support this [3]. The World
Health Organization recommended exclusive breastfeeding for six months in
2002 [4] and most of the international community has followed these
guidelines [5,6].

Feeding a baby with mothers' milk is a well accepted and well praised
behavior in the Sri Lankan culture. According to available national data, the
breastfeeding initiation rate in Sri Lanka is almost 100% and 54% of
mothers practice exclusive breastfeeding up to four months [7]. Data on
exclusive breastfeeding up to sixth months is scarce. A study conducted in
Colombo in 2003 reported that none of the study subjects were practicing
exclusive breastfeeding up to sixth months [8].

The national infant feeding policy guidelines in Sri Lanka have recommended
six months exclusive breastfeeding since 2005. Translation of the policy into
action would need immense planning and strong implementation. In a
country like Sri Lanka where the public health infrastructure is well

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developed compared to other countries in the region, the translation of these
policies into action would seem to be easy. But we strongly believe that all
public health programs originating at national level should be re-planned
according to the local requirements and should be carried out as objective
oriented programs in the local division.

In order to conduct a target oriented programme, it is essential to have

infant feeding base-line data such as exclusive breastfeeding rates, duration
of breastfeeding, and prevalence of infant formula feeding and the use of
bottles. The present study aimed to collect these data in order to develop a
successful programme to strengthen breastfeeding practices in the Medical
Officer of Health (MOH) area of Beruwala in Sri Lanka.

Methods

This study was a clinic-based descriptive cross-sectional study. The study

was conducted in the MOH area Beruwala which is situated in the most
southern part of the Kalutara district of the western province. The area is a
field practice area of the National Institute of Health Sciences (NIHS).
According to routinely reported data, the actual population residing in the
area in 2006 was approximately 160,000. Residents of the area are
comprised of multiethnic and multicultural groups. The Maternal and Child
Health (MCH) care is provided by the Medical Office of Health (MOH) through
Public Health Midwives and other support staff.

The study population consisted of mother-baby pairs attending Child Welfare

Clinics (CWC) where the infants were between the ages of four to twelve
months and currently residing in the MOH area of Beruwala. Infants with

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specific feeding problems (cleft lip and palate and primary lactose
intolerance), thus requiring infant formula or bottle feeding, were excluded
from the study as this group of infant would not be in the primary target
population for the promotion of exclusive breastfeeding. The sample size was
calculated assuming the rate of breastfeeding at six months of age as 20%,
precision level at 0.1, confident limits 95% and with a design effect of 2.
Final sample size was 211 [9]. Even though an earlier study reported six
month exclusive breastfeeding as zero [8] with the policy changes and
training of field and hospital staff, we estimated that it should be at least
20% by the time of the study.

A cluster sampling technique was used to collect data. A CWC clinic was
considered as a cluster and there were 19 functioning clinics in the area.
Clinic based cluster sampling had several advantages. The CWC clinics are
used only for immunization and growth monitoring purposes. Only healthy
children attend these clinics for immunization and ill children are usually
referred to specialized clinics. Therefore the sample would not be "biased" as
in other health facilities such as hospitals where only the "ill" children are
being taken. In Beruwala area there are no private providers for
immunization services and almost all infant immunizations are done in these
clinics. On the other hand growth monitoring during infancy is around 95%
in the area and weighing of infants less than six month of age is only done at
these clinics. Therefore a highly representative sample can be achieved by
conducting a clinic based study in this area.

Data were collected during June 2006 by the first two authors who had
undergone lactation management master training. Consecutive infants
fulfilling the inclusion criteria were enrolled in the study from each clinic until

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the required cluster size was reached. Study subjects were enrolled at all 19
clinics. Mothers were informed about the study and verbal consent was given
during the routine infant examination. A pre-tested interviewer administered
short questionnaire was used for data collection. Ethical approval was
obtained from the Scientific and Ethical Review Committee, Faculty of
Medicine, University of Colombo.

Data were entered into a Microsoft Access database and analyzed using
SPSS 13. Percentage, proportions and contingency tables were used for
description of the data. Association of inappropriate feeding practices and
socio-demographic characteristics were analyzed using chi-square test.
Kaplan-Meier survival analysis was used for the estimation of duration of
exclusive breastfeeding because some of the infants were continuing to
breastfeed exclusively (censored data) and the duration of exclusive
breastfeeding was a skewed distribution. For Kaplan-Meier survival analysis,
cessation of exclusive breastfeeding was taken as the final event. Individual
independent variables were transformed to dichotomous variables and
survival curves were compared using log-rank (Mantel-Cox) test in
univariate analysis. To assess the effect of all covariates, we used the Cox
proportional hazard model. Predictors of cessation of exclusive breastfeeding
were evaluated using regression coefficient and Wald test.

Exclusive breastfeeding was defined according to Labbok's strict definition;

that is exclusive breast feeding since birth [10]. Initiation of breastfeeding
was defined as the proportion of infants receiving breast milk regardless of
the time started (ever breastfed). The bottle feeding rate was defined as the
proportion of infants less than 12 month of age who were receiving any food
or drink through a bottle. Mothers who were actually working at the time of

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data collection or were employed but on maternity leave were defined as
"employed".

Results

A total of 219 infant-mother pairs were enrolled in study. The age range of
infants was 4 to 12 months with median age of 6 months. Table 1 shows the
characteristics of the study sample. Of the 219 mothers, 123 (56.2%) were
Sinhalese and 96 (43.8%) were Muslims. Primiparous mothers accounted for
43% of the sample. Two-thirds (61.2%) of the mothers were in their
twenties. Only one fourth of the mothers and one fifth of the fathers had
their highest educational level beyond grade 10. Seven percent of the
sample were "employed" mothers.

Table 1. Characteristics of the study sample (n = 219)

The breastfeeding initiation rate in this sample was 100%. Of the 219
infants, 135 (61.6%) were exclusively breastfed for four months. Only 155
infants were aged six months or more and only 24 (15.5%) of them were
exclusively breastfed for six months.

The sample selected for our study was not precisely representing the ethnic
composition in the Beruwala area. The proportion of Muslim mothers
(43.6%) was higher than the actual proportion (32.24%) residing in the area
[11]; the difference of proportions was statistically significant. This is one of
the drawbacks of using the cluster sampling technique. The final exclusive
breastfeeding estimation for the area could have been affected by these
ethnic differences. When ethnicity-adjusted exclusive breastfeeding rates

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were compared using population proportions as standards, 4 months and 6
months exclusive breastfeeding rates were 63% and 19% respectively.

Figure 1 shows the Kaplan-Meier survival estimates for the duration of

exclusive breastfeeding. Infants who were continuing to exclusively
breastfeed at the time of data collection were entered as censored data (n =
30, 13.8%). The median duration of exclusive breastfeeding was 4 months
(SE 0.219, 95% Confidence Interval: 3.75, 4.25). Major drops in exclusive
breastfeeding were observed after the third and fourth months.

Figure 1. Kaplan Meier survival estimates for duration of

exclusive breastfeeding.

We classified use of infant formula and feeding baby using a bottle as

inappropriate feeding practices, as even expressed breast milk should be
given using cup and spoon according to the national guidelines. Around two-
thirds of the infants (61.6%) received feeds by bottle. The proportion of
infants receiving infant formula was 23.3%.

Inappropriate feeding practices were compared with socio-demographic

characteristics (Table 2). Use of bottles was significantly higher among
Muslim mothers, among mothers with a lower level of education and among
unemployed mothers. Even though infant formula feeding had the same
pattern of association, only the ethnic differences were statistically
significant (p < 0.001).

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Table 2. Prevalence of inappropriate feeding practices according to socio-
demographic characteristics

The use of water and other water-based foods during the first six months of
life was quite high. The initial complementary feeds given to infants were
water (n = 39, 17.8%), water- based food (fruit juice, kanji water, soup
water etc.) (n = 19, 8.7%), infant formula (n = 26, 11.9%). Of the mothers
who started early complementary feeding before six months, only 47
(21.5%) had started food in semi-solid form.

Comparison of survival curves indicated that only ethnicity, parental

education and maternal employment were significantly associated with the
duration of exclusive breastfeeding. During the first two months exclusive
breastfeeding survival curves of both ethnic groups was similar (Figure 2).
After the second month, the exclusive breastfeeding rate had dropped
among Muslim mothers more rapidly compared to Sinhalese mothers (log-
rank test: chi square = 8.34, p = 0.004). The exclusive breastfeeding
survival curves of both mothers (Figure 3) and fathers (not shown) with
higher level of education were constantly higher than those of parents with
lower level of education. Comparison of survival curves using the log-rank
test indicated highly significant differences, for both mothers (p < 0.001, chi
square = 16.217) and fathers (p < 0.001, chi square = 17.084).

Figure 2. Comparison of ethnic groups regarding survival data

on exclusive breastfeeding.

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 Figure 3. Comparison of maternal educational level regarding
survival data on exclusive breastfeeding.

The exclusive breastfeeding survival curve of "employed" mothers was

constantly higher than that of non-employed mothers (Figure 4). Around
70% of "employed" mothers continued exclusive breastfeeding until
completion of fifth month, whereas only 60% of "non employed" mothers
continued exclusive breastfeeding up to four months.

Figure 4. Comparison of maternal employment status regarding

survival data of exclusive breastfeeding.

All independent variables that were significantly associated with exclusive

breastfeeding in univariate analysis were entered into the Cox proportional
hazard model to evaluate the covariates on hazard function for cessation of
exclusive breastfeeding and to remove the effect of confounders. In this
model, ethnicity and maternal employment was entered as categorical
variables, while other variables were entered as interval data. None of these
variables were significant predictors of cessation of exclusive breastfeeding
in this multivariate model. Table 3 summarizes the results of the Cox
regression analysis.

Table 3. Regression coefficient of covariates on cessation of exclusive

breastfeeding

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Discussion

Breastfeeding practices in Sri Lanka are considered the best in South East
Asia [12].

Over the past decade, reported exclusive breastfeeding practices were

increasing in the country. There has been number of studies on
breastfeeding in Sri Lanka [8,13-16] but published data on six month
exclusive breastfeeding are scarce.

In countries where lactation support is available, six months exclusive

breastfeeding has improved substantially over the time [4]. Estimated
current exclusive breastfeeding rate for six months duration is 58%
according to the Sri Lanka report card on breastfeeding published by the
International Baby Food Action Network (IBFAN) [10]. This is a fairly
reasonable estimation based on the 54% of four months exclusive
breastfeeding rate in the year 2000. National data for six months exclusive
breastfeeding is yet to be published. The estimate reported in our study is
well below expectations. This may be due to several reasons. A major
determinant of exclusive breastfeeding practices has been the health care
providers' knowledge, attitudes and skills for promotion of exclusive
breastfeeding. A knowledge assessment survey done on exclusive
breastfeeding in 2006, assessing all public health midwives (n = 70) in the
NIHS field practice area reported that only 50% of midwives had a good
understanding on the existing policy on recommendation of six months
exclusive breastfeeding [17]. It seems that the policy recommendation of
"four to six months" exclusive breastfeeding, which was practiced for several
years, had not been well understood by most of the health care providers.

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Change of recommendation from "four to six months" to six months has not
penetrated to the grass root level public health staff. This may be the reason
that the four months exclusive breastfeeding rate is much higher than six
months exclusive breastfeeding rate in this area. When we consider four
months exclusive breastfeeding rate, it was better than the national average
and could be one of the highest documented rates for Sri Lanka.

A decline in exclusive breastfeeding after the fourth month is common

elsewhere in the world [4]. Still we believed this drastic decline from 63% to
19% is highly unsatisfactory for a field practice area of the NIHS, as
prerequisites such as social support and proper health care infrastructure
with adequate resources to implement six months exclusive breastfeeding
had been already available in the area.

Prevalence of suboptimal feeding practices among infants was very high

among the study participants. The bottle feeding rate reported in the present
study (61.6%) was much higher than the study by Jayathilaka and Fernando
in 2002, which was 44% [16]. This difference cannot be attributed to ethnic
differences because Sinhalese infants also had a 50% bottle feeding rate.
This will be another major area where we should focus on when planning
infant feeding programs.

Both bottle feeding and formula feeding practices were significantly higher
among the Muslim ethnic group. This finding should be analyzed very
carefully. Language barrier has been a problem for provision of public health
care provision in Sri Lanka [18]. Lack of Tamil speaking midwives may have
contributed to this finding. But, cultural and religious practices and practices
among local subgroups affect exclusive breastfeeding rates all over the

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world. Studies in various countries have reported significant differences of
exclusive breastfeeding rates among ethnic groups.

Factors affecting breastfeeding have being reviewed extensively [15,19-23].

Maternal education and women's employment were two major determinants
described by most of those reviews as being associated with exclusive
breastfeeding. In the present study, parental education was significantly
associated with exclusive breastfeeding and it also showed a positive
correlation of exclusive breastfeeding with maternal employment. This may
simply be because of small number of employed mothers in the sample.
However, it may be a reflection of maternity benefits received by working
mothers through the extended maternity leave provision commenced in
2006. (Government provides 84 days fully paid maternity leave followed by
optional 84 days half paid maternity leave and 84 days no pay maternity
leave). Nevertheless, we recommend further studies to investigate the
relationship between maternal employment and exclusive breastfeeding in
Sri Lanka.

There were several limitations in our study. It was conducted as a base-line

data collection before the implementation of an exclusive breastfeeding
promotion programme. Therefore the sample size calculation was done using
0.1 as precision level which resulted in a small sample size which could have
affected some of our conclusions. There was a probability of overestimation
of proportion of exclusive breastfeeding due to selection bias. In Sri Lanka
infants who attend CWC clinics regularly are more likely to receive better
health education, support and motivation to continue exclusive
breastfeeding. Therefore clinic based sampling procedure may systematically
overestimate the final proportion. Another limitation of our study was the

27 | P a g e
use of Muslim mothers who were fluent in Sinhalese as translators. This may
have introduced biased estimation of exclusive breastfeeding rates, most
probably an overestimation. As the data collectors were also service
providers for the area there was a probability of underreporting of
unacceptable feeding practices and overestimation of exclusive
breastfeeding. Nevertheless the study found low exclusive breastfeeding rate
and high proportion of unacceptable feeding practices.

Conclusion

Our study revealed that the recommendation of six months exclusive

breastfeeding is not properly implemented in the MOH area of Beruwala.
This might indicate deficiencies of policy implementation at field level which
could be equally applied to other parts of the country. Proper planning and
results based programs through the existing system is needed with close
monitoring and timely evaluation to transform policy recommendations to
action at a field level. These results need urgent attention of programme
planners as well as divisional level service providers.

Competing interests

The author(s) declare that they have no competing interests.

Authors' contributions

SBA participated in the design, data collection, and manuscript preparation

and performed the data analysis. TCA participated in the design, data
collection and manuscript preparation. UKDP participated in design and

28 | P a g e
helped to draft the manuscript. All authors read and approved the final
manuscript.

Acknowledgements

We acknowledge the help given by the Beruwala area PHM and public health
nursing sisters throughout the conduct of this study.

CHAPTER THREE: OBJECTIVES

1. General objective
- To assess the KAP of mothers towards exclusive breast – feeding in Butajira Hospital .
Butajira Hospital SNNPR , Ethiopia
2. Specific objective
- To assess the knowledge of mothers in exclusive breast feeding
- To assess the altitude of mothers in exclusive breast – feeding
- To assess the practice of mothers in exclusive breast feeding

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 CHAPTER FOUR

METHODOLOGY

METHODS AND MATERIAL

Study area The study area was conducted in Butajira Hospital

Study design Institution based cross-sectional study was used
Source population : All mothers whose age in 15 – 49 having under two year child in
Butajira Hospital .
Study population : All mothers age in under 15- 49 ubdre two years child visiting
MCH service in Butajira Hospital from August 25 – September 2
Sample Design : All mothers whose age 15 – 49 who are coming to MCH service
during data collection from August & September 2 (non – probable convince
method).

Study Variables

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 - Age - Knowledge of EBF
- Sex - Attitude of EBF
- Religion - practice of EBF
- Occupation - Initiation of EBF
- Ethnicity - Time
- Education status - Frequency of breast feeding
- Marital status - Birth attendance
- Income of family -place of deliver
- Duration of breast feeding - ANC follow up

OPERATIONAL DEFINITION (STAND ARDS)

 Exclusive Breast feeding :- only breast for 0-6 month i.e with out any fluid liquid
 Time of imitation of Burdening :- initiated 1houre after birth
 Imitation of complementary feeding :- feeding fluid, semi-fluid feeding starting six
month and onwards.
 Duration of Breast Feeding :- total Breast feeding of 2years or more .
 Frequency of Breast feeding :-8to 12 feeding
DATA COLLECTIONN METHODS

Qualitative Data:- A protested structured questioner will be prepared in English and

translated to Amharic and for those people in the study area who don’t known Amharic
translators may used . the questionnaires. Will be interviewer administer question.
Data Collector:- An investigator under supper vision of advisor and will be collected for
two weeks.
Data quality assurance plan :- the questioner , which will prepared in English , will be
translated to Amharic orally by the principal investigators during interviewing and to have
common way of translation the then Constance was have pretest prior to the interview. Then
Constance or agreement will be assisted and adjustment measures was taken.
Pre test:- the structured questioner will protested on the study subjects using 5% of sample
size the principal in ventilators will conduct this and the necessary modification will be done.

31 | P a g e
 The quality of the data will be checked every day at the field for completed and consistency.
This also be done data century.

ETHICAL CONSIDERATION

First approval from the department of health officer , Jimma university of Health science and
supervisor was secured. Support letter from the department and local head of study population
was also secured. Study subjects were feeling an anonymous interviewed questionnaire. the
field questionnaire was not exposed to any other person other than the principal investigator all
the study have the right to stop at any time to continue .
PLAN FOR DISSIMNATION THE RESULT

First the study unit and respected bodies had been in formed about the findings. The report of
the study has submitted to the department of health officer . we . the principal investigators had
also presented finding at annual research seminars to be organized by the university.

32 | P a g e
 CHAPTER FIVE
5.1. Work plan
 

N Activity Month of the year

o
No De Ja Fe Ma A Ma Ju Ju Au Se Responsib
v c n b r p y n l g p le Body

1 Topic                        
selection and
Approval X

2 Finding the                        
related
Literature X

33 | P a g e
 3 Proposal                        
development
& X
submission

4 Literature                        
review
&data X
collection

5 Data           X            
Processing
& analysis

6 Submission                        
of the first
draft paper    
receiving
X  
comment

7 Submission                 X      
final
research

8 Defense                   X    

 
 

5.2. Budget Break down

S.No 1. stationary Unite Quantity Unit birr Cent Total Cent Remark

1 Duplicating paper Pack 3 28 00 84 00

2 Pencil Piece 5 1 00 5 00

3 Pen Piece 5 1 50 7 50
4 Note book Piece 5 1 00 35 00

5 Erases Piece 5 1 00 10 00

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6 Writing/Printing proposal questioner and 150 00
Research paper

Duplication cost of proposal questioner & 500 00

Research paper

8 Graph paper Piece 3 10 00 30

9 Marker pack 2 2 00 4
10 Staples Pack 2 2 00 4

11 Floppy (Diskette) Piece 2 5 00 10

12 Binder Piece 5 12 00 60
13 Clip board Pack 1 5 00 5

14 Transparency Piece 20 2 00 40
15 Phone service Card 150

16 Personal Data Collector Per day 5*8 35 00 1400

Total 2479 90

References

1. Jones G, Steketee RW, Black RE, Bhutta ZA, Morris SS: How
many child deaths can we prevent this year?
Lancet 2003, 362:65-71.
2 .Arifeen S, Black RE, Antelman G, Baqui A, Caulfield L, Becker S:
Exclusive breastfeeding reduces acute respiratory infection and
diarrhea deaths among infants in Dhaka slums.
Pediatrics 2001, 108(4):E67.

35 | P a g e
 3. World Health Organization: [http:/ / www.who.int/ child-
adolescent-health/ publications/ NUTRITION/
WHO_FCH_CAH_01.23.htm] webcite
Report of the expert consultation on the optimal duration of
exclusive breastfeeding. Geneva, Switzerland; 2002.
4. World Health Organization: Global Strategy on Infant and
Young Child Feeding. [http:/ / webitpreview.who.int/ entity/
nutrition/ publications/ gs_infant_feeding_text_eng.pdf] webcite
55th World Health Assembly Geneva, Switzerland; 2002.

5. National Health and Medical Research Council: Dietary Guidelines

for Children and Adolescents in Australia incorporating the Infant
Feeding Guidelines for Health Workers. Canberra, Australia:
Commonwealth Department of Health and Ageing; 2003.
6. American Academy of Pediatrics. Policy statement: Breastfeeding
and the use of human milk.
Pediatrics 2005, 115:496-506. PubMed Abstract |
Publisher Full Text
7. Department of Census and Statistics in collaboration with Ministry
of health nutrition and welfare 2002:
Sri Lanka Demographic and Health Survey. 2000.
8. Bundusena ASL: Selected determinants and sequelae of exclusive
breastfeeding up to six month in infants attending hospital and field
well baby clinics. MSc dissertation, Post Graduate Institute of
Medicine, University of Colombo; 2003.
9. Lwanga SK, Lemeshow S: Sample size determination in health
studies. A practical manual. Geneva: World Health Organization;
1991:1-3.

10. Labbok M, Krasovec K: Toward consistency in breastfeeding

definitions.
Studies in Family Planning 1990, 21(4):226-230. PubMed Abstract |
Publisher Full Text

11. DCS online: Number and percentages of population by

district. Census 2001.
[http://www.statistics.gov.lk/PopHouSat/PDF/Population/p9p8%20
Ethnicity.pdf] webcite
Department of Census and Statistics. Sri Lanka;

12. International Baby Food Action Network: The state of the

world's breastfeeding, Sri Lankan report card.
[http://www.worldbreastfeedingtrends.org/reportcard/Srilanka.pdf]
webcite

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 IBFAN Asia Pacific, New Delhi, India; 2006.

13. Senanayake MP, Weerawarna H, Karunaratne KW, De Silva TU:

Do babies need water in Sri Lanka?
Ceylon Med J 1999, 44:126-129. PubMed Abstract
14. Sorensen E, Fernando DN, Hettiarachchi I, Durongdej S, Podhipak
A, Skaara BB: Exclusive breastfeeding among women on the
plantations in Sri Lanka.
J Trop Pediatr 1998, 44:313-315. PubMed Abstract |
Publisher Full Text
Jayasuriya D, Sosa P: Feeding studies in Ceylonese babies.
J Trop Pediatr Environ Child Health 1974, 20:275-297.
PubMed Abstract
15. Jayathilaka CA, Fernando DN: A community-based study on
breastfeeding practices in Gampaha district.
Journal of the College of Community Physicians of Sri Lanka 2002,
7:32-36.

16. Agampodi SB: Annual Action Plan 2007, MOH area-Beruwala.

Medical Officer of Health Office, Beruwala; 2007.
17. Agampodi SB: Utilization of private sector for immunization of
children in Colombo municipal council area. MSc dissertation. Post
Graduate Institute of Medicine, University of Colombo; 2006.

18. Forman MR: Review of research on the factors associated

with choice and duration of infant feeding in less-developed
countries.
Pediatrics 1984, 74(4 Pt 2):667-694. PubMed Abstract
19. Koktürk T, Zetterström R: The promotion of breastfeeding
and maternal attitudes.
Acta Paediatr Scand 1989, 78:817-823. PubMed Abstract
20. Popkin BM, Bilsborrow RE, Akin SA, Yamamoto ME: Breast-
feeding determinants in low-income countries.
Med Anthropol 1983, 7:1-31.

21. Simopoulos AP, Grave GD: Factors associated with the choice
and duration of infant-feeding practice.
Pediatrics 1984, 74(4 Pt 2):603-614. PubMed Abstract
22. Wilmoth TA, Elder JP: An assessment of research on
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Soc Sci Med 1995, 41:579-594. PubMed Abstract |
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 ANNEXES

Annex I: Questionnaire

 JIMMA UNIVERSITY

COLLEGE OF PUBLIC HEALTH AND MEDICAL SCIENCES

Department of Public Health

38 | P a g e
 I. Socio democratic character sticks of the mother and child
II. Question Option III. c
od
S.no Age IV.
1 Religion 1.Orthodox V.
2. Muslim
Protestant
3. Catholic
5. Other specify
2 Ethnicity 1.Guraga VI.
2. Silte
3. Amhara
4. Other specify
3 Educational level 1. Illiterate VII.
2. Informal education
3. Grad 1-6
4. Grad 7-8
5. Grad 9-12
9. Grad 12
4 Martial status 1. Governmental employer VIII.
2. House wife
3. Merchant
4. Student
5. Dally laborer
6. Other specify
5 Occupational status 1. Government employer IX.
2. House wife
3. Merchant
4. Students
5. Daily laborer
6. Other (specify)
6 Monthly income <250 X.
>250
7 Age of infant XI.
8 SEX OF infant Male XII.
Female

II. Knowledge Questions

39 | P a g e
 XIII. Question Option cod
S.no Age
9 What is Exclusive Breast feeding?
10 What is the diminution of 1. <3
2. 3-4
3. 4-6
4. 6
5. >6
11 Is exclusive breast feeding is important?
1. Yes
2. No
12 If Yes, why? 1. Prevent diarrhea
2. prevent Respiratory
tract infection
3. Delay pregnancy
4. Others(Specify)
13 Is Breast milk is nutritionally enough for the 1. Yes
first six moths in the in fact ? 2. No
3. I don’t know
14 Is breast milk is nutritionally enough for the 1. Yes
first six months 2. No
3. I do not know
15 If yes which one do you know 1. Prevent you no child
From infection
2. Provide idea source
of nutrients
3. It is cost effective
4. Increase child and
mother bounding
5. Lower the risky child
hood death other
specify
16 Can HIV infected Mother protect her baby 1. Yes
by exclusive rest feeding 2. No
3. I do n’t know

III. Altitude questions

S. No Questions options code

40 | P a g e
17 Do you think size of breast affects the 1. Agree
amount of milk production? 2. Disagree
3. I don’t know
18 Do you think breast feeding has 1. Yes
effect on your posture ? 2. No
19 Do you think breast feeding has 1. Yes
impact on limitation of activity 2. No
20 Do you think exclusive breast feeding 1. Yes
can protect pregnancy? 2. No
21 Do you think beast feeding has 1. Yes
relation with pain and cancer ? 2. No

IV. practice question

S. No Questions options code

22 What is used to be given for new 1. Water
born baby at the first time ? 2. Breast milk
3. Butter
4. Ersho
5. Others(Specify)
22.1 It breast milk when did you start 1. <30
breast feed after birth ? ( In 2. 30-60
mineral) 3. -60
23 Do you give colostrums for the 1. Yes
indant 2. No
24 1. Hard to digest not pure
2. It cause stomach is pain, dirrbea
and irritate the mouth of new
born
3. Produce initial black stool (not
good for the infant while butter

41 | P a g e
 produced green stooly
4. Colostrums is concentration the
mother illness)
25 How do you breast feed 1. 8 times
2. 8-12 times
3. >12 times
26 If you are away for extended 1. Express a milk giving with
period what months ? cup bottle feed
2. Feeding care giver breast
milk
3. Other(Specify)
27 For how long did you breast feed
in month
28 Where did you deliver 1. Hospital
2. Health center
3. At room
29 Did you have ANC follow up 1. Yes
2. No
30 If no why 1. No health institution around
2. I don’t know important
3. Due to cultural Reason
4. Other

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