Exclusive Breastfeeding Practice and Associated Factors among Mothers having Infants (Aged 0-6 Months) in the Pastoral Community of Sawena District, Bale Zone Oromia, Ethiopia, 2023

Background: Breastfeeding is the recommended feeding method for infants due to its ease, health benefits, and cost-effectiveness. However, there is limited understanding of Exclusive Breastfeeding (EBF) in pastoral communities, such as the Sawena district in Ethiopia.

Objective: To assess the prevalence and factors associated with EBF among mothers with infants (aged 0-6 months) in pastoral communities in Southeast Ethiopia.

Method: A community-based cross-sectional study design with a convergent mixed-method approach was employed from March 01 to April 2023 G.C and involved 631 women selected through random sampling. Face-to-face interviews were conducted, and the data were analyzed using statistical software. Variables with a p < 0.25 in the analysis were included in the logistic regression model.

Results: Out of 631 eligible mothers, 625 participated in the study, resulting in 53.8% (95% CI; 49.8%-57.4%). prevalence of EBF in the study area. Factors significantly associated with EBF included household food security [AOR = 1.6, 95% CI (1.1-2.2)], ANC follow-up during pregnancy, [AOR = 5.3, 95% CI (2.4-11.9)], counselling about EBF during ANC visits [AOR = 5; 95% CI (2.1-11.7)], number of children [AOR = 1.6, 95% CI (1.1-2.3)] and attitudes toward EBF [AOR = 1.8; 95% CI (1.4-2.6)]. The qualitative findings revealed reasons for not practicing EBF, such as concerns about insufficient breast milk, concerns about the baby becoming thirsty, refusing solid foods later, or being negatively affected.

Conclusion: The prevalence of EBF in the Sawena district was lower than recommended. The influential factors include household food security, ANC follow-up, counselling during ANC, number of children, and attitudes toward EBF.

ANC: Antenatal Care; AOR: Adjusted Odds Ratio; CL: Confidence Level; COR: Crude Odd Ratio; EBF: Exclusive Breastfeeding; EDHS: Ethiopian Demographic Health Survey; HSDP: Health Sector Development Program; UNICEF: United Nation International Children’s Emergency Fund; WHO: World Health Organization.

Exclusive Breastfeeding (EBF) is defined as giving a baby just breast milk for the first six months of its life, without any additional food, drink, or water—aside from prescription drugs or vitamin and mineral supplements [1]. The World Health Organization (WHO) and the United Nations Children’s Fund (UNICEF) recommend initiation of breastfeeding within the first hour after birth; EBF should be done from the first six months of age and breastfeeding should continue until two years old or beyond, with adequate complementary foods [2].

EBF is an important public health strategy for improving children’s and mother’s health by reducing child morbidity and mortality and helping to control healthcare costs in society [3]. Moreover, one of the main tactics supporting the most well-known and successful intervention for preventing early childhood deaths is EBF [4]. In addition to its positive impact on the mother-child bond, breastfeeding reduces the risk of several childhood diseases, including pneumonia, ear infections, diabetes mellitus, diarrhoea, and sudden infant death syndrome [5].

The World Health Assembly (WHA) has set a global target to increase the rate of EBF for infants aged 0–6 months up to at least 50% in 2012-2025 [6]. Adherence to these guidelines varies globally, only 38% of infants are exclusively breastfed for the first six months of life [7]. High-income countries such as the United States (19%), United Kingdom (1%), and Australia (15%) [8]. have a shorter breastfeeding duration than nations with middle-class and lower-class incomes. Only 37% of new borns under six months old are exclusively breastfed, even in low- and middle-income nations [9]. According to recent papers in the sub-Saharan Africa region, only 53.5% of infants in East African countries were EBF for six months which is way below the WHO target of 90% [10].

In Ethiopia, approximately half (52%) of children less than six months old are exclusively breastfed. The practice of EBF at age 0-1 month is 70%, 55% at 2-3 months and 32% among 4-5-month-old infants [10]. Despite all the recognized benefits and efforts to promote EBF, practice is still far from the recommended levels. In Ethiopia out of 97% of breastfeeding, only 58% of mothers exclusively breastfeed. This number drops to 36% in infants aged 4-5 months [11]. Several associated factors have been identified with exclusive breastfeeding practices. Sociodemographic, environmental, and health facility-related factors are among the frequently cited factors [12].

The Ethiopian government has taken several steps to improve exclusive breastfeeding practices. The National Strategy on Infant and Young Child Nutrition, National Nutrition Program I and II, has been developed by the Government of Ethiopia to promote and improve the practice of exclusive breastfeeding during the first six months of life in collaboration with various stakeholders [13]. In addition, non-governmental organizations are also addressing the issue of optimal breastfeeding in different parts of the country through advocacy, community mobilization and the press [14].

Pastoralists comprise a significant part of Ethiopia’s population, but the promotion of exclusive breastfeeding at less than 6 months of age and its importance are poorly understood in pastoral communities [15]. Moreover, there is little information on the practice and factors associated with EBF less than 6 months of age in pastoral communities. In addition, information on the implementation and determinants of EBF in pastoral communities, especially pastoral areas is lacking and needs to be planned and intervened accordingly. To promote the benefits of EBF to the community, as well as to apply EBF properly to reduce the health impact, morbidity of infants and influence on economic growth due to not using EBF properly. Therefore, this study aimed to assess the prevalence of EBF and associated factors among women who have a child aged < 6 months in the study area.

Study design, period, and setting

A community-based cross-sectional study design with a convergent mixed-method approach was employed from March 01 to April 2023. In pastoral communities in the Sawena district, Bale Zone, Oromia Region, Southeast Ethiopia, mothers of infants aged 0-6 months were included. The Sawena district is approximately 675 km southeast east of Addis Ababa, with a latitude and longitude of 7° 23’ N 41° 16’ E and an elevation of 1161 meters. The estimated population size is 98751, 46,518 (47%) of which are males and 52,233 (53%) of which are females. Approximately 4% (2089) of the total women had babies less than 6 months old, and approximately 37% (17211) had babies. This district has 30 kebeles, 5 health centres, 32 health posts, 4 primary clinics, and 2 private drug stores. Different obstetric services, such as FP, ANC, delivery services, PNC, and counselling services, were provided at those health facilities. The majority of the climate conditions are dry (kola), 1/3 of the area is temperate (woynadaga), and Khat, peppers, fruits, Teff, and wheat are important cash crops for this woreda. Regarding occupation, the majority of the people in rural areas are pastoralists, and farmers dominate in rural areas.

Population

All mothers who had infants (aged 0-6 months) in the Sawena district pastoral community were the source of the population. The study population consisted of randomly selected mothers who fulfilled the inclusion criteria. For the qualitative part, healthcare professionals from maternal and child healthcare delivery, health extension workers, Traditional Birth Attendants (TBAs), and developmental health armies for Key Informant Interviews (KII) and mothers who had infants (aged 0-6 months) or caregiver in the Sawena district pastoral community were purposively selected for In-Depth Interviews (IDI).

Inclusion and exclusion criteria

Inclusion criteria: All mothers had infants (aged 0-6 months) and had been residents of the study areas for more than six months during the data collection period.

Exclusion criteria: Children with evidence of chronic health problems and mothers who were unable to communicate or were seriously ill and unable to provide information were excluded from the study.

Sample size determination

The sample size was determined using the single population proportion formula for the Epi Info STAT CALC cohort. version 7.2.4 Based on the assumptions of a 95% Confidence Level (CL), a 52% proportion of EBF practices [16], and 5% marginal error from the study conducted among mothers who had infants (aged 0-6 months) in the Somalia Region, Ethiopia, a 10% nonresponse and a 1.5 design effect, the final sample size was 631 mother-infant pairs. For the qualitative data collection, 12 participants were planned for IDI and 12 for KII. Data was collected from 18 participants. Due to the saturation of the idea.

Sampling procedure

A multistage, simple random sampling technique was used to select the study participants. In the first stage, nine kebeles were selected randomly from 30 kebeles in the districts. In the second stage, from the selected kebeles, a list of all eligible mothers with their Households (HHs) in each selected kebele was obtained from the kebele health post by using family folders collaborating with Health Extension Workers (HEWs). The sample size for each selected kebele was determined proportionally to the number of eligible HHs within each selected kebele. Finally, a simple random sampling technique was used to select the required number of eligible mothers from each kebele by using the HH listed as a sampling frame, which was obtained from family folders. If eligible mothers were not present at the time of data collection, a return visit was arranged a minimum of three times during the HH survey.

For the qualitative part, a purposive sampling technique was used to select participants for In-Depth Interviews (IDI) and Key Informant Interviews (KII). Mothers who had infants (aged 0-6 months) or caregivers in the Sawena district pastoral community, who were not included in the quantitative part, were purposively selected for IDIs. Healthcare professionals from maternal and child healthcare delivery, health extension workers, Traditional Birth Attendants (TBAs), and developmental health armies were chosen for KIIs.

Data collection procedures (tools, techniques and personnel)

A structured, closed-ended questionnaire developed from different kinds of literature [4,15,17] was used. The questionnaires consisted of six parts: sociodemographic factors, household food security status, infant and maternal health service utilization, knowledge about breastfeeding, attitudes towards EBE, and EBF practices. The data were collected through face-to-face interviews. Seven data collectors and one supervisor participated in the data collection process.

Qualitative data were collected in the local language (Afaan Oromo) by using semi-structured IDIs and KIIs guides. The guides were prepared in English by the authors, translated into Afaan Oromo, and checked by experts for more clarity. The guides had a list of a few interview questions such as Attitudes towards EBF, barriers to practice, and enablers of EBF with several follow-up probes used to capture the issue. The IDIs and KIIs were moderated by an experienced health professional with the assistance of a note-taker. At each selected site, the interview lasted between 30 minutes. Notes were taken during it, and their voices were recorded using a tape recorder.

Study variables

Dependent variable: Exclusive breastfeeding practice

Independent variable:

• Sociodemographic factors (maternal age, marital status, maternal education level, Mom’s occupation, and maternal knowledge of breastfeeding).
• Factors related to obstetrics and health services (parity, prenatal care, breastfeeding advice during pregnancy, place of birth, and how to give birth).
• Infant-related factors (infant age, infant sex, birth spacing)
• Economic factor: wealth index.
• Household Food Security Status.
• Attitudes toward EBF.

Operational definition

Exclusive breastfeeding: means feeding your baby only breast milk, not any other foods or liquids (including infant formula or water), except for medications or vitamin and mineral supplements 12

Wealth index: The wealth index was computed for ownership of different assets, house characteristics and types of animals. The resulting wealth indices were categorized into three categories: lowest, middle, and highest 5.

Practice of EBF: If a mother gives her only breast milk for her infant for the full 6 months, no other liquids or solids.

Data quality assurance

The questionnaire was pretested on 5% of the sample at Micha Kebele. The questionnaire was modified to enhance the consistency of understanding by the respondents as well as by the data collector. The data collectors were trained by the principal investigator about the general purpose of the study and the data collection procedures. The structured questionnaire was prepared first in English and then translated into the local language (Afan Oromo) by language experts. Finally, the data were checked for completeness before being entered into computer software for analysis.

For the qualitative part, to ensure the quality of the data, the PI considered trustworthiness, which is the fundamental criterion for qualitative reports such as credibility (internal validity), transferability, dependability (reliability) and conformability.

Data processing and analysis

The data were entered, cleaned and edited using EPI-data 4.6 and subsequently transferred to SPSS version 26 for further analysis. Descriptive statistics such as frequency, percentage, mean and standard deviation were calculated. Binary logistic regression was performed to assess the crude relationship between the independent variables and the dependent variable. All variables with a p value < 0.25 were candidates for multivariate logistic regression to control for possible confounding effects.

The multicollinearity was checked with Variance Inflation Factors (VIFs) and tolerance tests, which had VIFs less than 5 and tolerance tests less than 1; these values were used as cut-off points for diagnosing multicollinearity. Model fitness was checked using the Hosmer and Lemeshow goodness-of-fit model, and the results were fitted (p = 0.5). The final results of the associations are presented as AORs with 95% CIs, and a p < 0.05 was considered to indicate statistical significance.

Qualitative field notes were taken during the data collection session in addition to the tape recorder, after which the notes from all IDIs and KIIs were compiled and labelled according to participant type. The qualitative data were analysed using thematic analysis. The analysis started by transcribing Afan Oromo from records and then translating the results into the English language. The transcribed data were read carefully, categorized, and summarized manually.

Ethical considerations

The study protocol was approved, and ethical approval was provided by the Ethical Review Board of the Oromia Regional State Health Bureau (reference number IRB/688/15). The study was performed by the World Medical Association Declaration of Helsinki on medical research. Written informed consent was obtained from every study subject before the data collection. All the information collected from the study participants was handled confidentially by omitting their identification.

Sociodemographic characteristics of hypertensive patients

Out of the 631 eligible mothers, 625 participated in this study, for a response rate of 99.0%. The age of the mothers included in this study ranged between 17 and 40 years, with a mean age of 26.7 (SD = ± 4.2) years. Concerning ethnicity, 542 (86.7%) study participants were Oromo, while the majority (576; 92.2%) were religious Muslims. Regarding the educational status of mothers, the majority (64.2%) of them could not read or write. Almost all of the mothers, 615 (98.4%), were legally married. The majority of the respondents (225; 36.0%) were in the second wealth quintile group (Table 1).

Household food security status

Based on the calculated household food security, a total of 341(54.6%) of the sample households were food secure, and a total of 284 (45.4%) of the sample households were food insecure in the study area (Table 2).

Infant and maternal health service utilization characteristics

The majority (579; 92.6%) of the mothers had ANC visits during their recent pregnancy and were counselled about breastfeeding. The majority (524, 83.8%) of the mothers gave birth to their last child in health facilities (Table 3). The qualitative findings proved that the majority of the interviewees mentioned the ideal desire for exclusive breastfeeding, and most of the women interviewers mentioned, “Breastfeeding is our culture”. However, they perceived mixed feeding rather than exclusive breastfeeding. A 34-year-old breastfeeding mother said, “We have been informed by health professionals that giving cow’s milk and other foods, even water, to infants less than six months old is unnecessary”. "Even though most mothers receive breastfeeding counselling and antenatal care, they did not apply exclusive breastfeeding practices properly," the women interviewees confirmed. The MCH focal person described exclusively breastfed babies as having higher intelligence, being physically stronger, and being protected from illness. Babies who were exclusively breastfed were said to be much healthier than those who began consuming extra meals or liquids before the age of six months.

Attitudes toward exclusive breastfeeding practice

Of the 625 respondents, 609 (97.4%) agreed that EBF is necessary for their baby. In addition, 20 (3.2%) of the respondents considered breastfeeding to have cosmetically affected mothers’ shape. The majority of them (22) (35.8%) considered household economic capacity to determine mothers’ breastfeeding practices. The overall attitudes of the study participants showed that 319 (51.0%) of the respondents had positive attitudes toward EBF practices (Table 4).

This result is supported by findings from in-depth interviews.

A 48-year-old caregiver said, “Exclusive breastfeeding is important for the health and well-being of my baby”.

Another 34-year-old interviewer said, “I understand that the child should be breastfed for 6 months without mixing, but the problem is that he may refuse to take other food after 6 months”.

The 38-year-old mother who is breastfeeding stated that due to the intense heat in our environment, it is crucial to provide her baby with cold water to satisfy their thirst. She emphasized the importance of offering water to the newborn immediately after delivery and as frequently as they believe the baby requires it.

This finding presented some common traditional beliefs, myths, and misconceptions about exclusive breastfeeding, often shared by mothers and caregivers:

A 28-year-old mother said, "Breastfeeding exclusively for six months will cause the baby to be dependent on the mother."

A 31-year-old mother said "I couldn't exclusively breastfeed my baby because I was worried that breast milk alone wouldn't be enough for him. I heard from others in the community that babies need water to stay hydrated and that starting solid foods early will help prevent tummy issues."

A 41-year-old mother said "I was afraid that if I only breastfed my baby, I would become weak and anaemic. I thought I needed to eat specific foods or supplements to increase my milk production, and I was concerned about the impact on my health."

Exclusive breastfeeding practice

The prevalence of exclusive breastfeeding practice was 53.8%, within the 95% CI (49.8%-57.4%). Among mothers who did not exclusively breastfeed their infant, the main reasons mentioned were that the perception of breast milk alone was not sufficient for 323 infants (51.2%) (Table 5).

The qualitative findings proved that the majority of the interviewees mentioned that breastfeeding is important for the infant, but breastfeeding alone may not be sufficient for the infant until 6 months. Therefore, the mother should give additional food to her baby; otherwise, the baby should be starved, and the baby may refuse to consume food if he/she does not start early.

An old woman from the Health Developmental Army states that “mothers must care for their children by giving breast milk and other additional food after 4 months unless the baby may refuse food after 6 months if she/he didn’t start food early for her baby”.

A 28-year-old from the Health Developmental Army said that “only breast milk may not be sufficient for the baby until 6 months, so giving additional food and water after 4 months is important for the baby”. Some of the interviewees mentioned that early initiation and exclusive breastfeeding are important for the baby and the mother, so the baby must consume only breast milk until 6 months, but after 6 months, the baby should consume additional food because, after 6 months, only breast milk may not be sufficient”. An old TBA said that “As soon as the child is delivered, breast milk giving is necessary. The infant should only consume breast milk from birth to six months of age”. A 28-year-old multiparous woman interviewer states “I had never practised EBF in two of my babies because I believe the breast milk is not sufficient but for the third baby, I gave only breast milk for 6 months because the doctor told me to give only breast milk for 6 months”.

Factors associated with exclusive breastfeeding

Variables associated with a significance level of p < 0.25 in the bivariate analysis were considered candidates for the final multivariate analysis to determine their significant association with the practice of EBF. The independent predictors of EBF status included maternal educational status, household food security status, knowledge about EBF, number of children, birth order, birth interval, ANC follow-up, counselling about EBF during ANC service, place of birth, counselling about EBF during PNC service, attitudes toward EBF, and wealth index status.

The final predictors of EBF practices were household food security status, ANC follow-up during pregnancy, counselling about EBF during ANC services, number of children, and attitudes toward EBF. Mothers with a household food security status were 1.6 times more likely to practice good EBF than were those who were food insecure [AOR = 1.6, 95% CI (1.1-2.2)]. Mothers who had ANC follow-up data were 5.3 times more likely to practice EBF than women who had no ANC follow-up data [AOR = 5.3, 95% CI (2.4-11.9)]. Additionally, mothers who received counselling about EBF during ANC follow-up were 5 times more likely to practice EBF than mothers who did not receive such counselling (AOR = 5; 95% CI (2.1-11.7)) (Table 6).

The purpose of this study was to assess EBF practices and associated factors among exclusive breastfeeding mothers during the first six months of life. This study revealed that the prevalence of EBF in the pastoral community of Sawena District was 53.8%, within a 95% CI (49.8%-57.4%). These findings are similar to those of studies conducted in North West Ethiopia Mecha district (47.1%); Somalia region (52.0%); and other countries, such as Tanzania which had a prevalence of 55.0%, and Indonesia (51.2%) [6,18-20] respectively.

This percentage was lower than that reported in Debrebirhan (68.8%), Ambo (82.2%), Halaba (70.5%), Hawassa (60.9%) and Dubti afar (81.1%) respectively [15,21-24]. It was also lower than that reported in the 2019 mini-EDHS results, which was 59%, [25] and that reported in other countries, such as West Mamprusi District in Northern Ghana (84.3%) [5]. Conversely, this number was greater than that reported in studies performed in Addis Ababa (29.3%) [17]. Bangladesh (35.9%) [26] and Saudi Arabia (31.1%) [27]. Variations in healthcare coverage and health service accessibility may be the cause of this disparity. Another explanation can be the differences in the researchers' study time and design. Disparities in healthcare service utilization, sociocultural backgrounds, and economic status may have contributed to these variations both nationally and internationally.

Among the variables identified in the multivariate analysis, household food security status, ANC follow-up during pregnancy, counselling about EBF during ANC, number of children and attitudes towards EBF were significantly associated with EBF. The present study revealed that mothers with a household food security status were 1.6 times more likely to practice good EBF than mothers who were food insecure. This study is supported by other studies conducted in Ethiopia [4] and Bangladesh [28].

A possible explanation may be that when a household is food secure, meaning that it has consistent access to an adequate quantity and quality of food, it can positively impact a mother's ability to exclusively breastfeed her child. Food security ensures that the mother has the necessary nutrition to sustain her health and produce breast milk of sufficient quality and quantity to meet her infant's needs. In contrast, households experiencing food insecurity may face challenges in providing adequate nutrition for both the mother and the infant, which can potentially impact the practice of exclusive breastfeeding.

Another factor that was shown to have a significant association with EBF is the number of children. Mothers who had only one child were 1.6 times more likely to EBF their infants than were those who had five or more children. This finding is similar to those of studies conducted in Debre Markos, Northwest Ethiopia [12], the Mecha district, Northwest Ethiopia [20] and other regions, such as Tanzania [6] and Nepal [29]. This may be due to time and attention, which means that mothers with only one child may have more time and attention available to focus on breastfeeding and caring for their infant. With fewer children to whom to attend, they may have fewer competing demands and more flexibility to dedicate themselves to EBF.

This study also revealed that mothers who had ANC follow-up practised EBF better than mothers who did not. This finding is similar to those of studies performed in Northwest Ethiopia [10], Ambo [24] Halaba [22] and Dubti afar [15]. Moreover, in other countries, such as Tamandu, India [30], and Indonesia [19], this could be because mothers who attended ANC visits may receive different nutritional and other health-related education from health professionals during their follow-up appointments, which could have a significant impact on EBF. This effect might be attributed to the counselling provided to mothers regarding the importance of breastfeeding in health facilities during service delivery.

Mothers who received counselling about breastfeeding during ANC were 5 times more likely to exclusively breastfeed their infants than were those who did not receive counselling. Similar findings were observed in Dubti town, afar regional state, northeast Ethiopia, Somali region of Ethiopia, Mecha District, North West Ethiopia [15,18,20,22]and in other countries, such as Tanzania, Bangladesh, Nigeria and India [6,26,30,31]. A possible explanation may be that since ANC follow-up is a continuing process, mothers could receive much information, and this information may increase the knowledge and attitudinal changes regarding neonatal feeding practices, as well as the nutritional benefits of breast milk for the health of mothers and newborns.

Mothers who had positive attitudes toward EBF were more likely to practice EBF than those who had negative attitudes. This study is supported by other studies conducted in Ghana, a systematic review conducted in East Africa and Nigeria [7,31,32]. Possible reasons for this association may be that beliefs and perceptions of EBF-related attitudes reflect beliefs about the benefits and importance of breastfeeding for the health and well-being of both mothers and infants. Mothers who hold positive attitudes may have stronger beliefs about the nutritional value, bonding benefits, and immune-boosting properties of breast milk. These beliefs can motivate them to prioritize and commit to practising EBF.

Strength of the Study

The data were collected through both quantitative and qualitative research approaches, which adds value to strengthen the study design. The study was conducted in a general population that may be representative of other rural communities or pastoral communities in Ethiopia.

Limitations of the study

As a cross-sectional study, a cause-and-effect relationship cannot be established to identify an actual predictor. Since the data were self-reported, there may be social desirability bias and recall bias.

The prevalence of EBF found in this study was lower than the WHO-recommended level. This figure 1 is also lower than the national figure reported by the 2019 mini-EDHS. Household food security status, ANC follow-up during pregnancy, counselling about breastfeeding during ANC, number of children and attitude toward EBF practice were significantly associated with EBF. The qualitative findings revealed misconceptions that breastmilk alone is insufficient, leading to concerns about the baby becoming thirsty, refusing solid foods later, or being negatively affected. These misconceptions highlight the need for targeted education campaigns to promote the benefits of EBF and address these myths in the community.

Based on the findings of this study, the following points are recommended.

To Oromia regional health bureau and NGO’s

Train health workers to ensure that they have accurate and up-to-date information on infant feeding in general and breastfeeding/EBF in particular, which can help them to have the specific knowledge and skills required to educate and counsel mothers to improve EBF practices.

Suitable IEC materials for BFs should be developed to teach mothers at the home and facility levels. Availing family planning at all health facilities for spacing pregnancies can positively impact breastfeeding outcomes, as it allows for optimal maternal health and milk production, increasing the likelihood of successful EBF.

To the east bale zonal health department and district health office

There is a need to expand and strengthen maternal health services, specifically antenatal and postnatal care services, in line with the expansion of existing health services.

To healthcare providers

Maternal health services, specifically ANC and PNC services, should be strengthened and promoted to address all eligible individuals.

EBF counselling is an important part of all maternal and child health services, such as ANC, PNC, FP, vaccination and the IMNCI, for providing health education and counselling to mothers to improve their BF knowledge and subsequently improve their EBF practices.

To researchers

Further analytical studies, especially follow-up studies, are suggested to explore the actual levels of EBF and to further examine variables associated with this practice.

First and foremost, we would like to thank all the study participants for their participation in this study. Second, we would like to acknowledge the Ethical Review Board of the Oromia Regional State Health Bureau for the approval of the Ethical clearance for this study. Finally, we also thank the East Bale Zonal Health Office and the Woreda Health Office for providing baseline information.

Funding

The authors received no funding for this research.

Declaration of Conflicting Interests

The authors declare that they have no competing interests.

Research Ethics and Patient Consent

The study protocol was approved, and an ethical approval letter was provided by the Ethical Review Board of the Oromia Regional State Health Bureau (reference number IRB/688/15). The study was performed by the World Medical Association Declaration of Helsinki on medical research. Written informed consent was obtained from the study participants after the study objectives and procedures were explained, and their right to refuse not to participate in the study at any time was assured. For this purpose, a one-page consent letter was attached to the cover page of each questionnaire stating the general objective of the study and issues of confidentiality, which were also discussed by the data collectors before proceeding with the interview. The confidentiality of the information was ensured by coding. The interviews were privately conducted in an area separated from the others. Only authorized individuals were given access to the raw data collected from the field.

Data Availability Statement

The data that support the findings of this study are available from the corresponding author upon reasonable request.

Authors’ Contribution

D.H. and B.T.O. Conceptualisation, designed, and conducted the study D.H, S.M.I, B.T, M.S.L, B.B, S.B, B.M.K and B.T.O analyzed the data and drafted the manuscript, Software: S.B., D.G, S.M.I, M.S.L, B.B. and R.E.G. Validation: S.B., D.G., B.B, B.M.K and R.E.G. All of the authors read and approved the final manuscript. The data set used and/or analyzed during the current study is available from the corresponding author upon reasonable request.

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