Exclusive breastfeeding (EBF) is defined as “an infant’s consumption of human milk with no supplementation of any type (no water, no juice, no nonhuman milk, and no foods) except for vitamins, minerals, and medications until six months” [1]. EBF for six months is important for both infant and maternal health. Infants who are not exclusively breastfeeding are more likely to develop gastrointestinal infections, not only in developing but also in industrialized countries. The risk of mortality due to diarrhea and other infections can increase many-fold in infants who are either partially breastfed or not breastfed at all [1]. During the first two months of life, infants who are not breastfed are nearly six times more likely to die from infectious diseases than infants who are breastfed; between 2 and 3 months, non-breastfed infants are 4 times more likely to die compared to breastfed infants [2, 3].

Infant and young child feeding practices directly affect the nutritional status of children under two years of age and, ultimately, impact child survival. Worldwide, more than nine million children under five years of age die each year [4]. One in every 17 Ethiopian children die before the first birthday and one in every 11 children dies before their fifth birthday [5].

Over two-thirds of these deaths are associated with inappropriate feeding practices and occur in the first year of life. Optimal breastfeeding (early and exclusive breastfeeding) has the potential to prevent over 800,000 deaths (13 % of all deaths) in children under five in the developing world. Whereas, complementary feeding interventions alone were estimated to prevent almost one fifth of deaths in children aged years [4, 5].

Rates of EBF are suboptimal in many countries. In Saudi Arabia only by 8.3 % (n = 32) of the 384 participants EBF for 6 months [6]. In a study in Congo, 87.5 % of infants were EBF during the maternity stay, but by six months, only 2.8 % (n = 12) of infants were exclusively breastfed [7]. In a study done in Nigeria, the majority (88.0 %) of the respondents had heard about EBF and hospital was the source of information, and more than 50 % of the women had a positive attitude towards breastfeeding [8].

This community based cross-sectional descriptive study using ‘recall since birth’ method was conducted in April 2015, to assess Knowledge, Attitude and Practice towards exclusive breastfeeding among lactating mothers in Mizan Aman Town,South West Ethiopia. Mizan Aman town is located in Southern Nations Nationalities and Peoples Regional (SNNPR) State, 565 kilometers from Addis Ababa, the capital city of Ethiopia at a latitude and longitude of 7° N 35° E and an elevation of 1451 meters. Administratively, the town is structured into five kebeles (smallest administrative units) and two sub-cities. The economy of the town is widely based on trade of cash crops especially of coffee. There is 24 hours electricity, access to potable water, digital telephone access, postal service and a 70 bed hospital, health center and different private clinics, pharmacies and drug stores. It is also a location of three higher education institutions; Aman Health Sciences College, Aman Polytechnic College and Mizan Tepi University. The population of Mizan Aman town was estimated to be 47,776 in 2015. The number of children under 2 years of age is estimated to be 2475 (about 5 % of the total population) [17].

Firstly, population census was conducted in all five kebeles (three urban and two rural) and identified 1800 households of mother with index infant aged less than 2 years and currently breastfeeding their infants. A sampling frame was prepared and study subjects were selected from every fifth household using systematic random sampling techniques. During data collection,36 mothers and their index infants were replaced by the immediate next household due to incomplete or non- responses. Data were collected from 314 mothers with their index infant aged less than 2 years after explaining the purpose of the study, informed consent was obtained from each respondent.

The sample size was calculated using a single population proportion formula [n = [[Z [1 − α/2]]² X pX [1 − p]]/d²] with the following assumptions: 52 % prevalence of EBF at national level [5], 95 % confidence level, 5 % degree of desired precision, finite population correction factor formula [n = no/1 + no/N] since the total number of breastfeeding mothers in the city [N] was 2475 and 5 % for non-response rate. A total of 350 mothers were selected by systematic random sampling from households who had a child of less than two years old.

A structured interviewer administered questionnaire adopted from the EDHS (Ethiopian Demographic and Health Survey) and other literature was used to collect data. Three graduating class Bsc nursing students collected the data. The interviews were conducted in the compound of the mother’s home. The collected data were checked for completeness, coded and entered in to a computer. Statistical analysis was carried out using SPSS for Windows version 20.0. The data were summarized by descriptive statistics using the frequency, percentage and tables for categorical variables.

This study investigated KAP of EBF among mothers with children less than two years of age. The majority of study participants had heard about EBF (93.6 %) which was similar to other studies conducted locally and in other countries. A study in Bedele, Ethiopia found that the majority of mothers (91.8 %) knew the importance of EBF [11]. A study in Ambo Ethiopia found 90.8 % of mothers were knowledgeable about EBF [16] and a Nigerian study showed the majority (88.0 %) of the respondents had heard about EBF [8]. Although the majority of respondents had good knowledge about EBF, only about one third of mothers (34.7 %) mentioned the recommended duration of EBF, which was lower than a study in Debre Birhan Ethiopia in which 83.4 % of mothers were knowledgeable about the recommended duration of EBF [15].

In this study even though only 59.3 % believed that EBF is enough up to 6 months, the majority of mothers (89.5 %) preferred to feed their child breast milk only, which may be attributable to the recommendations and enforcements in some cases by health extension workers, the Health Development Army and other health professionals. Additionally most of the interviewed mothers could not afford to purchase extra food. This finding was similar to a study in Bedele, Ethiopia which found that the majority of mothers (87.3 %) had a positive attitude and strongly agreed that EBF is advantageous for infants aged less than six months [11], and a study in Debre Birhan Ethiopia which found 97.5 % of mothers had a positive attitude towards EBF [15]. The findings of this study showed a higher number of mothers with a favorable attitude towards EBF than in Southern Ethiopia (56.7 % of mothers had a favorable attitude towards EBF) [12] and in Nigeria (50 % of women had a positive attitude towards breastfeeding) [8]. This difference might be due to differences in sociodemographic characteristics of study samples such as differences in ethnic background, economic status, type of employment and educational status and differences in study period and study area.

In this study EBF was reported only by 26.4 % of mothers, which is lower than the national report in which 52 % of children less than six months were exclusively breastfed. This difference might be attributable to differences in sample: in the national study most of the surveyed areas were rural (437 rural areas from the total of 624 enumeration areas) while this study included urban kebeles and rural kebeles which are closer to town, and the national study included samples from all regions of Ethiopia including individuals with different sociocultural backgrounds while the present study was conducted in a single city administration [5].

EBF findings were lower than studies in other parts of Ethiopia including Arbaminch, Bedele, Southern Ethiopia, Harar, Gondar, Debre Birhan and Ambo which showed that 55.6, 43.6, 48.2, 51.8, 35.9, 68.6 and 82.2 % of mothers exclusively breastfed their children for 6 months respectively [10–16]. This difference might be due to lack of knowledge about optimal breastfeeding practices in which optimal breastfeeding was reported only about 34.7 %, due to field and home activities and due to the resumption of income-generating activities, might be due to difference in sociodemographic characteristics, differences in cultural habit and differences in the study area and period. This difference might also probably due to the chance to afford replacement feeding, so as to avoid breastfeeding. Additionally methodological differences occur because some studies like the DHS [5] calculated exclusive breastfeeding over a 24 hour recall period which appears to exaggerate the prevalence of EBF at six months [18], whereas this study used recall since birth method of defining EBF.

Our EBF findings were similar to a study in Addis Ababa, Ethiopia which found 29.3 % prevalence of EBF under six months [9], while it was higher than a study in Abha female educational district, Saudi Arabia in which EBF for 6 months was reported only by 8.3 % of participants (n = 32) [6] and a study in Kinshasa, Congo that found only 2.8 % of infants were exclusively breastfed (n =12) [7].

In this study even though the majority of mothers were knowledgeable about EBF and had a positive attitude towards EBF, knowledge with recommended duration of EBF, attitude of mothers towards sufficiency of EBF and EBF for 6 months was low. This study concluded poor knowledge and practice to EBF for the first six months postpartum among women in Mizan Aman Town.