Exclusive breastfeeding for the first six months of life and its associated factors among children age 6-24 months in Burao district, Somaliland

Background Adequate nutrition during early childhood ensures growth and development of children and breast milk is better than any other products given to a child. However, studies on exclusive breastfeeding practice are limited in Somaliland. Therefore, this study was aimed to assess exclusive breastfeeding for the first 6 months of life and its associated factors among children 6–24 months of age in Burao district, Somaliland. Methods A community-based cross-sectional study was conducted from 26 August to 10 October 2018, in Burao district among randomly, selected 464 mothers with children 6–24 months of age. Data were collected through face-to-face interview using pretested structured questionnaire. Results The prevalence of exclusive breastfeeding was 20.47% (95% CI 18.84, 23.63%). Exclusive breastfeeding practice was associated with: having female child (AOR 0.48; 95% CI 0.29, 0.80)), lack of formal education (AOR 0.32; 95% CI 0.19, 0.53), household monthly income 100$-200$ (AOR 0.35;95% CI 0.18, 0.68), lack of husband’s support (AOR 0.32; 95% CI 0.19, 0.53), and mothers who were not counselled on breastfeeding during antenatal care (AOR = 0.33; 95% CI 0.16, 0.66). Conclusions Exclusive breastfeeding practice was very low as compared to recommendations of infant and young child practice (IYCF) which recommends children to exclusively breastfeed for the first 6 months of life. Exclusive breastfeeding practice was associated with a mother’s lack of formal education, monthly income less than 100$, being a female child, lack of advice on exclusive breastfeeding during antenatal care and lack of husband support. The promotion of education for women, husband’s engagement, encouraging antenatal care follow-up and counseling of exclusive breastfeeding during antenatal care was recommended to improve exclusive breastfeeding practice.


Background
According to the definition the World Health Organization (WHO), Exclusive breastfeeding (EBF) is the situation in which an infant receives only breast milk from his/her mother or a wet nurse for the first 6 months and no other solids or liquids with the exception of drops or syrups consisting of vitamins, minerals, supplements, or medicines [1].
Globally, about 40% of infants were exclusively breastfed and this is expected to rise to 50% by 2025. Although the rates of EBF for the past two decades have been increasing, it is still a long road to achieve the 100% global target coverage recommended by UNICEF. This is evident in the current low prevalence of EBF in the developing world particularly in West and Central Africa which happen to have one of the highest rates of infant malnutrition in the world [2,3].
Despite the WHO recommendations and benefits of EBF, worldwide, only 39% of newborns were put to the breast within 1 h of birth, and only 37% of infants were exclusively breastfed. In Sub-Saharan Africa, 20% of women reported exclusive breastfeeding of their last born infant. In North Africa, the rate of exclusive breastfeeding is 41, 44% in Asia, and the lowest in Latin America at 30% [4,5].
Overall poor breastfeeding practice, particularly exclusive breastfeeding had been broadly documented in the developing countries and only about 25% of infants in Africa were exclusively breastfed. Additionally, 6% of infants in developing countries were never breastfed [6]. Globally, of 56 million infants, approximately 22 million were exclusively breastfed, while over 34 million children were not. Previous studies showed that 80 % of these children who did not benefit from exclusive breastfeeding in developing countries reside in only 29 countries. From these 29 countries, the 10 large countries including Ethiopia have two-thirds of the approximate numbers of non-exclusively breastfed children [7][8][9].
In Somaliland, malnutrition is a huge public health problem, negatively affecting the growth, development, and survival of young children. Malnutrition has been aggravated by poor infant and young child feeding practices and other contributing factors including the long-term armed conflict and insecurity, and the breakdown in social and public services. Recurrent droughts and flooding also seriously affecting food security. Existing evidence show that infant feeding practices in Somaliland are alarming and only 13% of the infants have been exclusively breastfed [8]. Exclusive breastfeeding was challenged by a lack of knowledge and different sociocultural beliefs; the incorrect beliefs that breastfeeding mothers are unable to produce enough milk to exclusively breastfeed their child for the first 6 months of life and that society believes that breastfeeding mothers look older than their age. The other barriers include, societal or peer pressure to bottle feed their child. In order to overcome this problem, the Ministry of Health of Somalia and UNICEF has been working together to improve the infant and young child feeding practices.
Exclusive breastfeeding for the first 6 months is one of the infant and young child feeding practices recommended by WHO which can be appropriately assessed by this lifelong EBF practice over time point EBF practice, because the time point EBF practice is mostly assessed by 24 h recall which cannot give us guarantee about the 6 month course EBF practice.
The low prevalence of EBF in most developing countries is attributed to various maternal and child-related factors such as place of residence, sex, age of the child, number of births and space between children, mother working outside home, maternal age and educational level, economic status, mothers' domestic work burden, access to mass media, maternal healthcare access and use, and maternal knowledge on infant and young child feeding practices [4,[10][11][12][13][14][15][16].
There is a paucity of scientific research that investigate the prevalence of EBF and factors affecting EBF in Somaliland, particularly in the study area. Therefore, this study was aimed to determine the exclusive breastfeeding practice for the first 6 months and its associated factors among mothers having children 6-24 months of age in Burao, Somaliland.

Study design and setting
This community-based cross-sectional study was conducted among children aged 6-24 months of age in Burao district, Somaliland, 260 km away from Hargeisa the capital city of Somaliland. The climate of the region is semi-arid and it has a total population of 406,866 [17]. Regarding the health facilities, the city has eight hospitals (two public hospitals and six private hospitals), three health centers, and more than 10 private clinics. The study was conducted from 26 August to 10 October, 2018.
The final sample size was 474 mothers. From the five zones in Burao town, two zones were selected by lottery method. Each zone had 12 villages and four villages were selected randomly from each selected zone. The sample size was allocated into the selected eight villages proportionally to the number of mothers with children between 6 and 24 months of age. Systematic random sampling technique was used to select respondent to be interviewed within the selected villages. For those who have had more than two eligible respondents in the same house, lottery method was applied to choose one amongst.

Data collection tools and quality assurance procedures
Data were collected using structured interviewer administered questionnaire (Additional file 1) which is adopted and modified from different literatures [1,12,15,18]. The questionnaire was first prepared in English and translated to Somali and finally retranslated back to English by a person who can speak both languages. The questionnaire consisted of sociodemographic factors (age, marital status, educational level, monthly income, sex of the child); obstetric and health service related factors (place of delivery, ANC visit, number of ANC visit, postnatal services, colostrum feeding) and psychosocial factors (husband support, family support, knowledge of the mother on EBF). A pretest among 24 (5%) of the sample prior to the actual data collection was carried out in nearby village other than those included in the actual study. Mothers who had 6-24 months old children were asked about their lifelong (6 month course) EBF practice using their recall response. Mothers are categorized as practicing EBF practice if they exclusively breastfeed their child for 6 months, but if they exclusively breastfeed for less than 6 months they are categorized as they don't practice exclusive breastfeeding. To assess knowledge about EBF, respondents were asked 10 questions on importance of EBF, duration of EBF, contents of breast milk. Respondents that correctly responded > 7 knowledge questions were considered as having good knowledge on EBF, and those who respond < 7 knowledge questions are categorized as having poor knowledge on exclusive breastfeeding. Three trained accountants and five information technicians (IT) collected the data. Three trained public health professionals and the principal investigator supervised the data collection process.

Data processing and analysis
Data were coded and entered into SPSS Version 21 software for analyses. Descriptive analysis including frequency distribution, proportion and mean was performed to summarize the characteristics of the study subjects. To identify factors associated with exclusive breastfeeding practice, firstly bivariable logistic regression was performed. Subsequently, significant variables in the bivariable analysis (p -value < 0.05) were incorporated into the multivariable logistic regression. Statistical significance was declared at p < 0.05 and the corresponding 95% CI.

Sociodemographic characteristics of the study participants
Four hundred sixty-four mothers who had children between 6 to 24 months of age were included in the study making the response rate of 98%. The mean (± SD) age of the study participants was 27.10 (+ 5.1) years. Two hundred seventy-six (59.5%) of the study participants were in the age range of 25-34 years followed by those in the age range of 15-24 years which accounts for 140 (30.2%). Nearly half of the women 224 (48.2%) had formal education. Two hundred fifty-four (54.7%) of the mothers earned an average monthly income of less than the 246$ (Table 1).

Obstetric history and health service related factors
Of the 464 mothers who participated in the study, 194 (41.8%) of the mothers had more than three living children at the time of the study. The majority (72.2%) of the mothers had at least one antenatal care (ANC) follow up during their last pregnancy, of which (77%) had four and above ANC visits. Close to one third (28.2%) of the mothers had at least one child death. Close to threefourth (73.1%) of the mothers gave birth at a health institution. Of the 464 mothers, 79.7% had received advice on breastfeeding (Table 2).

Psychosocial factors
Of the 464 mothers who participated in the study, only 163 (35.1%) were receiving support from their husbands. However, 155 (33.4%) of the mothers reported that they received help from other family members. More than half of the mothers 265 (57.1%) had poor knowledge about exclusive breastfeeding (Table 3).

Exclusive breastfeeding practices
The prevalence of exclusive breastfeeding practice was 20.47% (95% CI 18.84, 23.63%). Almost all the mothers had breastfed at least once in their life time to their youngest child. About 419 (90.3%) of the mothers were still breastfeeding their children during the study period. From all respondents, only 36 (7.8%) of the mothers expressed and discarded their colostrum; 18 (50%) of these mothers who expressed believed that colostrum causes abdominal cramps (Table 4).

Factors associated with exclusive breastfeeding practices
According to the multivariable logistic regression analysis, educational level of the mother, average family monthly income, sex of the child, ANC visit, and support from husband were identified as statistically significant factors for exclusive breastfeeding practice. Mothers who did not attend formal education and mothers who attended elementary schools were 68 and 52% less likely to exclusively breastfeed their children than those who attended secondary school and above (AOR 0.32; 95% CI 0.19, 0.53 and AOR 0.48; 95% CI 0.29, 0.80).
The average family monthly income was another factor that was found statistically associated with exclusive breastfeeding. Mothers with monthly house hold income of 100$-200$ were 65% less likely to exclusively breastfeed their children than mothers with monthly house hold income of 400$ and above (AOR 0.35; 95% CI 0.18, 0.67). This study revealed that female child was 52% less likely to exclusively breastfeed than male child (AOR 0.48; 95% CI 0.29, 0.80).
Attending an ANC visit was another factor found significantly associated with exclusive breastfeeding practice Mothers who received an ANC visit were 67% less likely to exclusively breastfeed their children than those who had no ANC (AOR 0.33; 95% CI 0.16, 0.66). Additionally, Mothers who did not get support from their husbands were 68% less likely to exclusively breastfeed their children than those who received support from their husband (AOR 0.32; 95% CI 0.19, 0.53) ( Table 5).

Discussion
The prevalence of exclusive breastfeeding in our study is lower than the findings of the Somaliland national policy of exclusive breastfeeding [17], and a study done in Indonesia which shows EBF as 26.2% [19] and 64% in Ghana [20]. Additionally, our finding is lower than the previous study conducted 57.6% in a southern part of Ethiopia [4]. This variation might be due to the socioeconomic status of the participants and or access to a health facility and most of the other studies have a lower sample size compared to this study. Study setting difference might contribute to this difference like the study done from Addis Ababa, Ethiopia which was a health facility-based study and could contribute to an increased awareness about EBF practice by the counseling provided during an ANC visit. Age differences between the study subjects might also be a reason because children less than 6 months of age were included in the study from Ghana [20]. Additionally, the low EBF rates in our study might be due to definition of EBF by which this study uses lifelong EBF other than the point time exclusive breastfeeding. This study revealed that mothers who did not attend formal education and mothers who attended elementary schools were less likely to exclusively breastfeed their children than those who attended secondary school and above. However uneducated mothers exclusively breastfeed their child in a study done in Ethiopia [7]. Another study showed no association between the level of education and practice of exclusive breastfeeding in Somalia [17]. The association found in our study might be due to the role of education in improving awareness about EBF practice and increasing health seeking behaviors like attending an ANC visit.
In this study, mothers with a monthly house hold income of 100$-200$ were 65% less likely to exclusively  breastfeed their children than those with monthly house hold income of 400$ and above. A study conducted in Kenya also stated that income has positive association with exclusive breastfeeding [12]. The observed association might be due to the role of income in improving exposure to various media that can improve their knowledge on EBF practice. Sex of the child was significantly associated with exclusive breastfeeding in this study. A female child was 52% less likely to be exclusively breastfeed than male child. A similar finding was found in a study done in India [21]. However, this finding is not consistent with study done in Nigeria [15]. The association found in this study might be due to the values given for males and females in the community. Mostly, having a baby boy resulted in feeling more pride for the family and due to this, a mother might focus more on baby boys than girls while they feed.
This study indicated that receiving antenatal care was associated with exclusively breastfeed, similar to the positive association observed in Tanzania. This could be due to mothers attending antenatal services being exposed to information about exclusive breastfeeding.
Additionally, support from a husband was associated with exclusive breastfeeding practice. Mothers who did not get support from their husbands were 68% less likely to exclusively breastfeed their children than those who got support from their husband. A study conducted in Hong Kong is in line with the finding of this study [18]. This might be due to the role of husband support in promoting exclusive breastfeeding. As mothers are asked to remember and respond the duration of exclusive