Timely Initiation of Breastfeeding and Associated Factors among Mothers of Infants Attending Pediatric Department at Yekatit12 Hospital Medical College Addis Ababa Ethiopia 2019G.C

Introduction: Timely initiation of breastfeeding is defined as putting the newborn to the breast within one hour of birth. Timely initiation of breastfeeding has a major contribution to the survival of newborns. In developing countries, early initiation of breastfeeding could save as many as 1.45 million lives each year. However, there is paucity of data about it. This study aimed at assessing timely initiation of breastfeeding and associated factors among mothers of infants attending the pediatric department at yekatit12 hospital medical college. Methods: An institutional based cross-sectional study was conducted from June to July 2019. A total of 228 mother-infant pairs were included in this study. The data were collected using face to face interview. Both bi-variable and multivariable logistic regression analyses were used to identify factors associated with timely initiation of breastfeeding. The results were presented using descriptive and analytic analyses. P-values < 0.05 were considered statistically significant. Results: prevalence of timely initiation of breastfeeding in Addis Ababa Yekatit 12 Hospital was 69.7%. place of delivery home (AOR = 6.19; 95 CI = 1.43, 9.29), ANC follow up (AOR = 5.73;95 CI = 3.94, 8.68) and maternal health condition immediately after delivery(AOR = 1.267; 95 CI = 1.062, 3.54) were significantly associated with timely initiation of breastfeeding. Conclusion: In this study timely initiation of breastfeeding was less as planned set by the Ethiopian Ministry of Health’s Health Sector Development Program Four (HSDP-IV). Strengthening timely initiation of breastfeeding through provision of antenatal care services, educating mothers and strengthening health professional’s knowledge, and skills on breastfeeding counseling were recommended.


Background of the Study
Timely initiation of breastfeeding is defined as putting the newborn to the breast within 1h of birth [1]. Breast Milk is the best food for the infant for the first 6 months of life and it should be initiated within 1 hour of birth, even before the expulsion of the placenta [2]. The advantages of early initiation of breastfeeding include: increases bonding between mother and infant, reduces the risk of upper respiratory tract infections in the child, enhances dental development, aids in cognitive development, and decreases the risk for obesity in later life [3]. Timely initiation of breastfeeding has a major contribution to the survival of neonates. The study showed that 22% of neonatal mortality could be prevented if breastfeeding is initiated within the first hour [4]. Despite this fact only (45%) of newborns started breastfeeding within the first hour of life globally, the result is even lower in developing countries, for example, West and Central Africa (40%), East Asia and Pacific (44%), South Asia (42%), Latin America and Caribbean (49%), Eastern and southern Africa (59%) of newborns initiated breastfeeding within an hour of delivery [5]. In Ethiopia, breastfeeding practice is universal were more than 90% of mother's breastfeed, but it is sub-optimal [6,7]. In Ethiopia neonatal mortality rate was 37 deaths per 1,000 live births [8]. If all babies started breastfeeding within one hour of live birth, it would reduce to 22% of all neonatal deaths [9] which will contribute to the achievement of the Millennium Development Goal IV that contributes to the two-thirds reduction in child mortality. Timely initiation of breastfeeding is influenced by several factors: illiteracy [10,11], being rural residents, mothers who had not been following antenatal care [12], home delivery [12,13], cesarean section and cultures beliefs [14].
In developing countries alone early initiation of breastfeeding could save as many as 1.45 million lives each year by reducing deaths mainly due to diarrheal disorders and lower respiratory tract infections in children [15]. Despite improvements in the prevalence of EIBF from 52% in 2011 to 74.3% in 2016, this percentage still falls well short of the EIBF target of 92% set by the Ethiopian Ministry of Health's Health Sector Development Program Four (HSDP-IV) [16]. This indicates the presence of existing barriers or new barriers that necessitates further investigations. Therefore, the purpose of this study was to assess timely initiation of breastfeeding and associated factors among mothers of infants attending the pediatrics department at yekatit12 hospital medical college Addis Ababa Ethiopia.

Significance of the Study
Early initiation of breastfeeding saves many infants if it is practiced timely and barriers were avoided. Therefore, this study plays a significant role in the following: • Used by policymakers while designing an intervention that improve timely initiation of breastfeeding strategies by revealing the cause for not starting timely initiation of breastfeeding • For nursing education department, incorporate into the curriculum.
• For the mothers, to improve quality of life.
• To hospitals, to shift budgets for designing strategies and to decrease hospitalization. • Identify factors affecting the timely initiation of breastfeeding among mothers of infants attending the pediatric department at yekatit12 hospital medical college, Addis Ababa Ethiopia.

Study area
The study was conducted in Addis Ababa the capital city of Ethiopia. This study was conducted at Yekatit 12 Hospital Medical College.
It is one of the referral hospitals in Addis Ababa among six hospitals where a large number of mothers gave birth. There was a total of 228 study samples of study participants who had children less than six months and visited the pediatric department in the study area.

Study period
The study periods were from July 1 st -July 30, 2019.

Study design
The institutional-based cross-sectional study design was conducted to assess timely initiation of breastfeeding and associated factors among mothers of infants attending the pediatric department at Yekatit12 Hospital Medical College Addis Ababa Ethiopia 2019.

Source population
All mothers of infant less than six months of age visited pediatrics departments at Yekatit12 Hospital Medical College.

Study population
Samples of mother with infants of age less than six months attending pediatric department at Yekatit12 Hospital Medical College.

Sample size determination
To determine the number of mothers who were included in the study, the single population proportion formula was used based on the following assumption: a) The level of confidence of the study 95%, b) Margin of error is 5%, c) The proportion (P) is 88.8% which estimates the prevalence of timely initiation of breastfeeding among urban women's conducted at eastern Ethiopia in 2014 [11].
Accordingly, by using the following single population formula of the sample size:  Since the study sampling population is less than 10,000 which is 476.
To get sample from the total population, used correction formula. The exact sample size; therefore, is calculated as follows: The final sample size is 228.

Sampling procedure
The sampling procedure for the research was a systematic random sampling method. Every K th value (two) was included in study.

Inclusive criteria
• Mothers who have less than six months of age Infants and visited pediatrics department were included in study.

Exclusive criteria
• Mothers who were unable to respond to the interview because of hearing impairment and communication problem,

Timely Initiation of Breastfeeding and Associated Factors among Mothers of Infants Attending Pediatric Department at Yekatit12
Hospital Medical College Addis Ababa Ethiopia 2019G.C 17 • Mothers who were not willing.

Dependent variables
• Timely initiation of breastfeeding.

Independent variables
• Socio-demographic factors: Age, educational status of the mother.
• Obstetric factor: Place of delivery, birth attendant, mode of delivery and parity, full term and preterm baby.
• Health service related factors: Attendance of antenatal care services, number of antenatal visits, advice on TIBF by healthcare staff during ANC and mothers counseled on TIBF at PNC.
• Traditional belief: Removing of colostrum and pre lacteal feeding.

Data collection tool and quality assurance
Data were collected using a pre-tested interviewer-administered structured questionnaire. The questionnaire was adopted from related literature [13][14][15] and translated into the local language. It contains socio-demographic information, obstetric factors, health service related factors, and traditional belief related factors. The instrument validity was assured by applying validity criteria and reliability assured by the stability of responses of participants under similar situations.

Data processing and analysis
The data was cleaned and entered into Epi Info 7.1.4.0 software. Then it was exported into SPSS version 20 for analysis. Descriptive analysis was computed to determine frequency of the variables. Binary and multivariable logistic regressions were used to identify factors that affect early (Timely) initiation of breast feeding; the degree of association between independent and dependent variables was assessed using odds ratio with 95% confidence interval. Finally, variables with p < 0.05 on the multivariable logistic regression analysis model were statistically significant with the outcome variable.

Data quality control
A training that focused on understanding the research question, sampling technique, data handling, ethical conduct, and quality of data collection was given for two days for the four data collectors and two supervisors. Each data collector checked the questionnaires for completeness before winding up their visit to each study participant and each questionnaire was reviewed daily by the supervisors and the principal investigator to check for its completeness and early corrections and cleaned of the data were made.

Ethical consideration
Ethical clearance was obtained from and in order to obtain permission letter received at Yekatit12 hospital medical college. We were contact. Then the participants was informed about the purpose of the study, the importance of the study, full confidentiality, withdraw at any time and written consent was obtain prior to data collection. Privacy and confidentiality of information given by each respondent was

Timely Initiation of Breastfeeding and Associated Factors among Mothers of Infants Attending Pediatric Department at Yekatit12
Hospital Medical College Addis Ababa Ethiopia 2019G.C 18 keep properly and number code was used otherwise names was not record.
Ethical approval was obtained from Ethical review committee of Saint Paul Hospital Millennium Medical College. A formal letter was obtained from medical service administrative office of the hospital. The participants were informed about the purpose, procedures, and benefits of the study. Written informed consent was obtained from the participants. The information obtained was kept anonymous, thereby ensuring confidentiality. The study participants were ensured that refusal or withdrawal from the study would not put at risk their access to care.

Results
A total of 228 mothers with response rate of 100% were included in the study. Most of the respondents were between the age 25 -29 which accounts 35.5% and majority of mothers (52.6%) were housewives. Among the respondent's most of the mothers were educated (91.7%). From all respondents' (69.7%) feed their infant timely (within one hour) while the rest (30.3%) started to feed after one hours of delivery.
Most of the respondents (98.7%) attended ANC at least 3 visit and 1.3% did not attend ANC during their pregnancy.
Most of the respondents (93.4%) didn't squeeze and throw colostrum while 6.6% of them squeeze and throw breast milk than feeding their newborn.

Timely Initiation of Breastfeeding and Associated Factors among Mothers of Infants Attending Pediatric Department at Yekatit12
Hospital Medical College Addis Ababa Ethiopia 2019G.C 19 In the bivariate logistic regression analysis (See table 2), found existence of strong relationship between timely initiation of breastfeeding and mothers place of delivery, ANC follow up, mothers who have admitted to hospital after delivery, those who squeeze and throw colostrum. Those who gave birth at the health institution are 3.35 more likely to start timely initiation of breast feeding than those who gave birth at home (COR = 3.35; 95% CI = 2.32, 4.89). The participants who have admitted to hospital after delivery due to illness are 1.54 times less likely to initiate timely breastfeeding than those who did not (COR = 1.54; 95% CI = 1.37, 3.50). No statistically significant relationship was detected between respondent's level of education, those who give anything to eat/drink, mothers who sleep with their baby while admitted and timely initiation of breastfeeding of mothers.
Variables that were found to be statistically significant in the bivariate analysis at p-value < 0.05 were included in the multivariate logistic regression to identify factors that best predict timely initiation of breast feeding among breastfeeding mothers. As shown in table   2, only place of delivery, ANC follow up and mothers who were admitted after delivery due to illness was significantly associated with timely initiation of breastfeeding among breastfeeding mothers. In this regard, respondents who gave birth at the health institution were 6.19 more likely to initiate timely breastfeeding than those who gave birth at home (AOR = 6.

Discussion
This study assessed timely initiation of breast feeding and associated factors among mothers of infants at Yekatit 12 Referral Hospital and majority of mothers (69.7%) fed their infant timely (within one hour) of delivery while the rest (30.3%) starts to fed after one hours of delivery. The finding of this study was almost comparable with the study conducted in Dembecha district where 73.1% of mothers initiated breastfeeding timely [18].
Furthermore, this finding was higher than the findings of studies in South Gondar and Debrebirehan town where only 48.1% and 62.6% of mothers, respectively, were initiated breast feeding timely [19,20]. In addition, this finding was higher compared against study or a systematic review and meta-analysis made on sixteen studies all over Ethiopia (61.4%) [21]. The variation of the findings might be presence of cross cultural habit of the respondents and difference in design.

Timely Initiation of Breastfeeding and Associated Factors among Mothers of Infants Attending Pediatric Department at Yekatit12
Hospital Medical College Addis Ababa Ethiopia 2019G.C 21 The prevalence of timely initiation of breastfeeding in this study was higher than that reported in Pakistan (29%), India (41%), Bangladesh (47%) and Nepal (45%) [22]. similarly, the finding of this study was also higher than other sub-Saharan countries Demographic and Health survey (DHS based studies: Nigeria (47%) and Tanzania (52%) [23]. The possible explanation for higher rate of early initiation of breastfeeding in this study could be due to the fact that methodological difference, variation in infant and maternal socio-demographic characteristics, economical and health service utilization.
On the other hand, the prevalence of timely initiation in this study was lower than the findings of studies done in Bahir Dar, Motta and Wolayita town in which timely initiation of breastfeeding was 75.4%, 78.8% and 81.1% respectively [24][25][26].
In this study mothers who gave birth at health institution were almost 6.19 times more likely to initiate breastfeeding within 1 hr. as compared to women who gave birth other than health institution. This is consistent with studies which have been conducted in South

Conclusion and Recommendations
Prevalence of timely initiation of breast feeding in the study area was low compared to EDHS 2016 plan. Therefore, Antenatal care, institutional delivery should be strengthened.