In order to achieve optimal growth, development and health, the World Health Organization (WHO) and the National Nutrition Programme (NNP) of Ethiopia recommend that infants should be exclusively breastfed for the first six months of life, which means that infants should receive only breast milk except prescribed medications, vitamins, and minerals [1, 2]. The Government of Ethiopia strives to address under-nutrition through the Lifecycle Approach which includes ensuring that newborns are breastfed within one hour of birth and that exclusive breastfeeding (EBF) continue for the first six months, followed by adequate complementary feeding [2]. Breastfeeding has a significant role in improving nutrition, education, and maternal and child health [3].

Though studies showed that EBF has a potential to reduce under- five mortality by 11.6%, the prevalence of EBF is still relatively low globally, as in sub Saharan Africa with a magnitude of 35% and 22–33%, respectively [4]. According to WHO, 90% EBF practice strongly reduces the incidence of infant mortality due to pneumonia [5]. The prevalence of EBF varied from country to country. For example, in Canada 10.4% of mothers exclusively breastfed [6], while in the Republic of Congo 2.8% did so [7]. On the contrary the prevalence of EBF was higher in developing countries than in developed ones, 49% in Timor, Asia, and 35.4% in Korea [8, 9].

Studies conducted on EBF in Ethiopia reported a variety of findings ranging from 29.3% in Addis Ababa [10] to 81.1% in Dubti town, northeast Ethiopia [11]. The prevalence also varied from locality to locality within the region, and was 50.1% for Motta district [12], and 79% for Azezo district [13] both of which are to the northwest of the Amhara Regional State, respectively. In addition to the disparities of EBF practice in different places of Ethiopia, it seems that according to reports from different authors, the country might not reach the target set to be achieved by 2019/2020 which is 93% [14]. Understanding the factors that hinder this target point might be helpful to carry out an intervention in improving the practice.

Different studies indicated various factors that could influence EBF practices. A study conducted in Nova Scotia, Canada, showed that EBF was associated with maternal education and family income [6], but these were not the predictors for EBF practice in a study in Indonesia [15]. Maternal age was a significant factor in the study done in sub-Saharan Africa, but not so in Indonesia [15, 16]. A study carried out in Italy indicated that antenatal care was a significant factor for EBF practice [17], but not the study done in Nigeria [18].

In Ethiopia, maternal age was not an independent predictor of EBF according to a study done in Dabat, northwest Ethiopia [19], but it was a significant factor in Debre Berhan, central Ethiopia [20]. In the study in Dabat, family income was not a significant predictor for EBF practice [19], while it was statistically associated with EBF according to a study done in Awi Zone, northwest Ethiopia [21].

As can be seen from the literature in Ethiopia, there were inconsistencies of prevalence of EBF as well as factors associated with it. This is what motivated us to conduct this study in an area where no similar study has been conducted to date.

This study has attempted to assess the magnitude of exclusive breastfeeding practice and associated factors during the first six months of infant life among mother-infant pairs in Gozamin district, northwest Ethiopia. The prevalence of EBF was 74.1%. This finding was greater than that of a study conducted in Dabat district, northwest Ethiopia, whose prevalence of EBF was 30.7% [24]. It was also higher than the national level prevalence of 52% reported by Ethiopian Demographic and Health Survey (EDHS) in 2011 [22]. This difference could be the result of efforts and multi-sectoral collaborations that have been made by the Government of Ethiopia on child nutrition since 2013 [14], while the studies mentioned above used data collected before the implementation of these revised national nutrition programs. In addition, the national study included samples from the less developed and pastoral regions with less health service coverage, which might have resulted in less awareness about exclusive breastfeeding.

Regarding factors that could affect EBF, occupation of the mother, place of delivery, and breastfeeding counseling after delivery were statistically significantly associated with EBF practice. Accordingly, government employed mothers were less likely to practice EBF compared to housewife mothers. This finding is in line with those of studies done in the rural communities of northwest Ethiopia [24], eastern region of Ghana [25], Kinshasa [7], and Saudi Arabia [26]. Perhaps this is because employed mothers have no time to exclusively breastfeed their infants, or they have short maternity leave to stay with and establish breastfeeding their newborn babies, or they lack convenient locations to breastfeed at their working places. On the contrary, a study done in Bangladesh showed that mothers working outside their houses were more likely to practice exclusive breastfeeding. The possible explanation for this difference might be that in Bangladesh most women take their babies to their work places [27].

In this study, mothers who delivered at health institutions were more likely to practice exclusive breastfeeding compared to mothers who delivered at home. These findings were similar to a study done at Dabat Health and Demographic Surveillance System site in northwest Ethiopia [24] and Ghana [28]. This might be so because mothers who gave birth at health institutions could have more chance to receive obstetric and postnatal care, nutritional education and counseling on the benefits of breastfeeding, correct positioning, and attachment.

Exclusive breastfeeding in this study is significantly associated with breastfeeding counseling after delivery. This result is supported studies done in Debre Berhan district, central Ethiopia [20], Addis Ababa public health centers, Ethiopia [10], and Kilimanjaro Region, northern Tanzania [29]. One possible explanation for the observed association could be that breastfeeding counseling after delivery might have helped mothers to improve their maternal knowledge regarding exclusive breastfeeding.

In our study, antenatal care visits were not significantly associated with EBF practice. However, in studies conducted in Dabat, northwest Ethiopia [24], among urban women at Addis Ababa public health centers, Ethiopia [10], and Timor-Leste [8] indicated that mothers who had antenatal care visits had a better practice of exclusive breastfeeding. The possible reason for this difference might be that in this study mothers who attended antenatal care did not receive breastfeeding counseling.

The incidence of exclusive breastfeeding in this work was relatively high compared to other previous studies. A mothers’ occupation, giving birth at health facilities, and the provision of counseling about breastfeeding after delivery were significantly associated with EBF practice. Therefore, we suggest that health institutions encourage hospital birthing and increase breastfeeding counseling after delivery. Employers need to consider giving longer maternity leave to improve exclusive breastfeeding practice.