Open access Research

Evidence on the effect of gender of

newborn, antenatal care and postnatal
care on breastfeeding practices in
Ethiopia: a meta-analysis and
meta-regression analysis of
observational studies
 1,2
Tesfa Dejenie Habtewold, Nigussie Tadesse Sharew,1 Sisay Mulugeta Alemu3

To cite: Habtewold TD, Abstract

Sharew NT, Alemu SM. Strengths and limitations of this study
Objectives  The aim of this systematic review and meta-
Evidence on the effect of gender analysis was to investigate the association of gender of
of newborn, antenatal care and ►► This systematic review and meta-analysis was
newborn, antenatal care (ANC) and postnatal care (PNC)
postnatal care on breastfeeding conducted based on the registered and published
practices in Ethiopia: a meta- with timely initiation of breast feeding (TIBF) and exclusive protocol.
analysis andmeta-regression breastfeeding (EBF) practices in Ethiopia. ►► Since this is the first study in Ethiopia, the evidence
analysis of observational Design  Systematic review and meta-analysis. could be helpful for future researchers, public health
studies. BMJ Open Data sources  To retrieve all available literature, practitioners and healthcare policy-makers.
2019;9:e023956. doi:10.1136/ PubMed, EMBASE, CINAHL, WHO Global Health ►► Almost all included studies were observational
bmjopen-2018-023956 Library, Web of Science and SCOPUS databases were which might weaken the strength of evidence and
►► Prepublication history and systematically searched and complemented by manual hinder causality inference.
additional material for this searches. The search was done from August 2017 to ►► Perhaps, the results may not be nationally repre-
paper are available online. To September 2018. sentative given that studies from some regions are
view these files, please visit Eligibility criteria  All observational studies including cross- lacking.
the journal online (http://​dx.​doi.​ sectional, case-control, cohort studies conducted in Ethiopia ►► Based on the conventional method of heterogeneity
org/​10.​1136/​bmjopen-​2018-​ from 2000 to 2018 were included. Newcastle-Ottawa Scale
023956).
test, a few analyses suffer from high between-study
was used for quality assessment of included studies. variation.
Received 4 May 2018 Data extraction and synthesis  Study area, design,
Revised 1 April 2019 population, number of mothers (calculated sample size
Accepted 17 April 2019 and participated in the study) and observed frequency
Conclusions  In line with our hypothesis, gender of
data were extracted using Joanna Briggs Institute tool.
newborn, ANC and PNC were significantly associated with
To obtain the pooled effect size, a meta-analysis using
EBF. Likewise, ANC was significantly associated with TIBF.
weighted inverse variance random-effects model was
Optimal care during pregnancy and after birth is important
performed. Cochran’s Q X2 test, τ2 and I2 statistics were
to ensure adequate breast feeding. This meta-analysis
used to test heterogeneity, estimate amount of total/
study provided up-to-date evidence on breastfeeding
residual heterogeneity and measure variability attributed to
practices and its associated factors, which could be useful
heterogeneity, respectively. Mixed-effects meta-regression
for breastfeeding improvement initiative in Ethiopia and
analysis was done to identify possible sources of cross-country and cross-cultural comparison.
heterogeneity. Egger’s regression test at p value threshold Trial registration number CRD42017056768
≤0.01 was used to examine publication bias. Furthermore,
the trend of evidence over time was examined by
© Author(s) (or their performing a cumulative meta-analysis. Introduction
employer(s)) 2019. Re-use Results  Of 523 articles retrieved, 17 studies (n=26 146
WHO and Unicef recommend timely initia-
permitted under CC BY-NC. No mothers) on TIBF and 24 studies (n=17 819 mothers) on
commercial re-use. See rights tion of breast feeding (TIBF) (ie, initiating
EBF were included in the final analysis. ANC (OR=2.24,
and permissions. Published by 95% CI 1.65 to 3.04, p<0.001, I2=90.9%), PNC (OR=1.86,
breast feeding within 1 hour of birth) and
BMJ. exclusive breast feeding (EBF) (ie, feeding
95% CI 1.41 to 2.47, p<0.001, I2=63.4%) and gender of
For numbered affiliations see newborn (OR=1.31, 95% CI 1.01 to 1.68, p=0.04, I2=81.7%) only human milk during the first 6 months)1
end of article. for maintaining maternal and newborn
significantly associated with EBF. ANC (OR=1.70, 95% CI 1.10
Correspondence to to 2.65, p=0.02, I2=93.1%) was also significantly associated health.2 Breast feeding provides optimal nutri-
Tesfa Dejenie Habtewold; with TIBF but not with gender of newborn (OR=1.02, 95% CI tion, increase cognitive development, reduce
​tesfadej2003@​gmail.​com 0.86 to 1.21, p=0.82, I2=66.2%). morbidity and mortality for the newborn; for

Habtewold TD, et al. BMJ Open 2019;9:e023956. doi:10.1136/bmjopen-2018-023956 1

Open access

example, TIBF prevents 22% of neonatal deaths.3 Inap- Search strategy and databases
propriate breastfeeding practice, on the other hand, PubMed, EMBASE, CINAHL, WHO Global Health Library,
causes more than two-thirds of under-five child mortality, Web of Science and SCOPUS electronic databases were
of which 41% of these deaths occur in Sub-Saharan searched to extract all available literature. The search
Africa.1 4 Breast feeding also prevents maternal long-term strategy was developed using Population Exposure Controls
chronic diseases, such as diabetes mellitus.3 and Outcome (PECO) searching guide in consultation with
According to a new 2017 global Unicef and WHO a medical information specialist (online supplementary file
report, only 42% start breast feeding within an hour of 1). The search was done from August 2017 to September
birth, leaving an estimated 78 million newborns to wait 2018. Grey literature and cross-references of included arti-
over 1 hour to be put to the breast, the majority born in cles and previous meta-analysis were also hand searched.
low-income and middle-income countries.5 The preva-
lence rate of TIBF varies widely across regions from 35% PECO guide
in the Middle East and North Africa to 65% in Eastern Population
and Southern Africa. Another report also shows that only All mothers with newborn up to 23 months of age.
two in five infants <6 months of age are exclusively breast
fed.6 The prevalence rate of EBF ranges from 22% in East Exposure
Asia and Pacific to 56% in Eastern and Southern Africa.6 Gender of the newborn, ANC and PNC visit (at least one
Based on our meta-analysis in 2018, the prevalence of visit).
TIBF and EBF in Ethiopia is 66.5% and 60.1% respec-
Comparison
tively.7 To date, globally, only 22 nations have achieved
Female newborn, no ANC visit and no PNC visit.
the WHO goal of 70% coverage in TIBF and 23 countries
have achieved at least 60% coverage in EBF.2 Outcome
To promote optimal breast feeding, WHO, Unicef and TIBF and EBF practices.
other (inter)national organisations have been working
in developing countries, and several studies have been Inclusion and exclusion criteria
conducted on the advantages of breast feeding. However, Studies were included if they met the following criteria:
it is still challenging to achieve the expected coverage (1) observational studies including cross-sectional,
and attributed to several factors including antenatal case-control, cohort studies; (2) conducted in Ethiopia;
(ANC), postnatal care (PNC) and gender of newborn,8 9 (3) published in English language and (4) published
and breastfeeding coverage continued to be suboptimal between 2000 and 2018. Studies were excluded on any
as a result. In Ethiopia, several meta-analyses studies one of the following conditions: (1) conducted in women
were done on infant and young child feeding.7 10–14 In with HIV/AIDS, preterm newborn and newborn in inten-
our previous meta-analysis, we explored the association sive care unit; (2) published in language other than
between maternal employment, lactation counselling, English; (3) abstracts without full text and (4) qualita-
mode of delivery, place of delivery, maternal age, newborn tive studies, symposium/conference proceedings, essays,
age and discarding colostrum breastfeeding practices (ie, commentaries and case reports.
TIBF and EBF).7 10 We also separately studied the associ-
ation between TIBF and EBF.7 However, none of these Selection and quality assessment
meta-analyses did study the pooled effect of gender Initially, all identified articles were exported to Refwork
of newborn, ANC and PNC on TIBF and EBF. Given citation manager (RefWorks 2.0; ProQuest LLC, Bethesda,
the absence of pooled estimates, up-to-date evidence is Maryland, USA, http://www.​ refworks.​
com), and dupli-
required to design intervention-based studies targeting cate studies were cancelled. Next, a pair of independent
these factors. Therefore, we aimed to investigate whether reviewers identified articles by analysing the title and
TIBF and EBF in Ethiopia are influenced by gender of abstract for relevance and its compliance with the proposed
newborn, ANC and PNC. We hypothesised at least one review topic. Agreement between the two reviewers, as
ANC or PNC visit significantly improves TIBF and EBF measured by Cohen’s Kappa,16 was 0.76. After removing
practices. Additionally, mothers with male newborn have irrelevant studies through a respective decision after discus-
higher odds of TIBF and EBF compared with mothers sion, full texts were systematically reviewed for further
with female newborn. eligibility analysis. Newcastle-Ottawa Scale (NOS) was used
to examine the quality of studies and for potential risk of
bias.17 In line with the WHO standard definition, outcome
measurements were TIBF (the percentage of newborn who
Methods breast feed within the first hour of birth) and EBF (the
Protocol registration and publication percentage of infants who exclusively breast fed up to 6
The study protocol was registered with the University of months since birth). Finally, Joanna Briggs Institute (JBI)
York, Centre for Reviews and Dissemination, International tool18 was used to extract the following data: study area
prospective register of systematic reviews (PROSPERO) (region and place), method (design), population, number
and published.15 of mothers (calculated sample size and participated in

2 Habtewold TD, et al. BMJ Open 2019;9:e023956. doi:10.1136/bmjopen-2018-023956

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the study) and observed data (ie, 2×2 table). Geographic study participants through health education on factors
regions were categorised based on the current Federal affecting breast feeding and disseminating the key find-
Democratic Republic of Ethiopia administrative structure.19 ings using brochure in the local language.
Disagreement between reviewers was solved through discus-
sion and consensus.
Results
Statistical analysis
Search results
A meta-analysis using a weighted inverse variance
In total, we obtained 533 articles from PubMed (n=169),
random-effects model was performed to obtain a pooled
EMBASE (n=24), Web of Science (n=200), SCOPUS
OR. In addition, a cumulative meta-analysis was done to
(n=85) and CINHAL and WHO Global Health Library
illustrate the trend of evidence regarding the effect of
(n=5). Fifty additional articles were found through
gender of newborn, ANC and PNC on breastfeeding prac-
manual search. After removing duplicates and screening
tices. Publication bias was assessed by visual inspection
of titles and abstracts, 84 studies were selected for full-
of a funnel plot and Egger’s regression test for funnel
text review. Of these, 43 articles were excluded due to
plot asymmetry using SE as a predictor in mixed-effects
several reasons: 19 studies on complementary feeding, 3
meta-regression model at a p value threshold ≤0.010.20
studies on prelacteal feeding, 3 studies on malnutrition,
Duval and Tweedie trim-and-fill method21 was used to
17 studies with different variables of interest and 1 project
manage publication bias. Cochran’s Q X2 test, τ2 and I2
review report. As a result, 41 articles fulfilled the inclu-
statistics were used to test heterogeneity, estimate amount
sion criteria and used in this meta-analysis: 17 studies
of total/residual heterogeneity and measure variability
investigated the association between TIBF and gender of
attributed to heterogeneity, respectively.22 Mixed-effects
newborn and ANC whereas 24 studies between EBF and
meta-regression analysis was done to examine the effect
gender of newborn, ANC and PNC. The PRISMA flow
of variation in study area (region), residence of women,
diagram of literature screening and selection process is
sample size and publication year on between-study
shown in figure 1. One study could report more than one
heterogeneity.23 The total amount of heterogeneity (R2)
outcome measures or associated factors.
accounted for these factors was calculated by subtracting
the residual amount of heterogeneity from the total Study characteristics
amount of heterogeneity and dividing by the total amount As presented in table 1, 17 studies reported the asso-
of heterogeneity. Moreover, to assess the moderation ciation of TIBF and gender of newborn and ANC in
effect of these factors, Omnibus test of moderators was 26 146 mothers. Among these studies, 13 of them were
applied. The data were analysed using ‘metafor’ packages conducted in Amhara (n=5), Oromia (n=4) and Southern
in R software V.3.2.1 for Windows.23 Nations, Nationalities and Peoples’ (SNNP) (n=4)
Data synthesis and reporting region. Regarding the residence status, eight studies were
We analysed the data in two groups based on outcome conducted in both urban and rural whereas six studies in
measurements (ie, TIBF and EBF). Results are presented urban women. All studies passed the NOS quality assess-
using forest plots. Preferred Reporting Items for System- ment criteria at a cut-off value ≥7.
atic Reviews and Meta-Analyses (PRISMA) guideline was Twenty-four studies reported the association between
strictly followed to report our results.24 EBF and gender of newborn, ANC and PNC in 17 819
mothers. Of these studies, 11 were conducted in Amhara
Minor post hoc protocol changes and seven in SNNP region. Based on the residence
Based on the authors’ decision and reviewers' recom- status, 10 studies were conducted in urban, 8 in urban
mendation, the following changes were made to our and rural, and 6 in rural women. Even though almost
published protocol methods.15 We added the JBI tool18 all studies were cross-sectional, five studies have used
to extract the data. In addition, we used the Duval and nationally representative data of the Ethiopian Demo-
Tweedie trim-and-fill method to manage publication bias. graphic Health Survey.19–23 Detailed characteristics of the
Furthermore, cumulative meta-analysis and mixed-effects included studies are shown in table 2.
meta-regression analysis were done to reveal the trends of
evidence and identify possible sources of between-study Meta-analysis
heterogeneity, respectively. Timely initiation of breast feeding
Among the 17 selected studies, 10 studies25–34 reported
Patient and public involvement the association between TIBF and gender of newborn in
The research questions and outcome measures were 16 411 mothers (table 1A). The pooled OR of gender of
developed by the authors (TDH and NTS) in consulta- newborn was 1.02 (95% CI 0.86 to 1.21, p=0.82, I2=66.2%)
tion with public health professionals and previous studies. (figure 2). Mothers with male newborn had 2% higher
Given this is a systematic review and meta-analysis based chance of initiating breast feeding within 1 hour of birth
on published data, patients/study participants were not compared with female newborn although not statistically
directly involved in the design and analysis of this study. significant. There was no significant publication bias
The results of this study will be disseminated to patients/ (z=0.41, p=0.68) (online supplementary figure 1).

Habtewold TD, et al. BMJ Open 2019;9:e023956. doi:10.1136/bmjopen-2018-023956 3

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Figure 1  PRISMA flow diagram of literature screening and selection process; ‘n’ in each stage represents the total number
of studies that fulfilled particular criteria. EBF, exclusive breast feeding; PRISMA, Preferred Reporting Items for Systematic
Reviews and Meta-Analyses; TIBF, timely initiation of breast feeding.

Likewise, 13 studies27 28 30 31 33–41 reported the associa- for gender of newborn (OR=1.31, 95% CI 1.01 to 1.68,
tion between TIBF and ANC in 12 535 mothers (table 1B). p=0.04, I2=81.7%) after including imputed studies
The pooled OR of ANC was 1.70 (95% CI 1.10 to 2.65, (ie, estimated number of missing studies=4) (online
p=0.02, I2=93.1%) (figure 3). Mothers who had at least supplementary figure 3). Therefore, mothers with male
one ANC visit had 70% significantly higher chance of
newborn had 31% significantly higher chance of exclu-
initiating breast feeding within 1 hour of birth compared
sive breast feeding during the first 6 months compared
with mothers who had no ANC visit. There was no signif-
icant publication bias (z=0.96, p=0.34) (online supple- with mothers with female newborn.
mentary figure 2). Twenty-one studies35–37 42–49 51–60 reported the asso-
ciation between EBF and ANC in 16  052 mothers
Exclusive breast feeding (table 2B). The pooled OR of ANC was 2.24 (95% CI 1.65
Out of the 24 studies included, 11 studies25 26 42–50 to 3.04, p<0.0001, I2=90.9%) (figure 5). Mothers who
reported the association between EBF and gender of
had at least one ANC visit had 2.24 times significantly
newborn in 6527 mothers (table 2A). The pooled OR of
newborn gender was 1.08 (95% CI 0.86 to 1.36, p=0.49, higher chance of exclusively breast feed compared with
I2=71.7%) (figure 4). Since significant publication bias mothers who had no ANC visit. There was no significant
detected (z=−3.64, p<0.001), we did Duval and Tweedie publication bias (z=1.69, p=0.09) (online supplemen-
trim-and-fill analysis and calculated a new effect size tary figure 4).

4 Habtewold TD, et al. BMJ Open 2019;9:e023956. doi:10.1136/bmjopen-2018-023956

 Table 1  Characteristics of included studies on TIBF
TIBF
Author/publication Sample size/ Within
year Study area Study design Study population Participated Factors 1 hour After 1 hour Total
A. Gender of newborn versus TIBF
Regassa 201425 SNNPR, Sidama Cross-sectional Mothers with infants aged 1100/1094 Male 488 107 595
zone study between 0 and 6 Female 389 110 499
months old
Total 877 217 1094
Alemayehu 201426 Tigray, Axum town Cross-sectional Mothers who had children 418/418 Male 75 141 216
study aged 6–12 Female 99 103 202
months
Total 174 244 418
Berhe et al 201327 Tigray, Mekelle town Cross-sectional Mothers of children aged 361/361 Male 166 42 208
study 0–24 months Female 112 37 149
Total 278 79 357
28
Beyene et al 2 016 SNNPR, Dale Cross-sectional Mothers of children 634/634 Male 262 51 313
Woreda study <24 months Female 255 50 305

Habtewold TD, et al. BMJ Open 2019;9:e023956. doi:10.1136/bmjopen-2018-023956

Total 517 101 618
29
Lakew et al 2 015 National Cross-sectional Mothers who had children 11 654/11 553 Male 3124 2860 5984
study* <5 years Female 3057 2511 5568
Total 6181 5371 11 552
Liben and Yesuf Afar, Dubti town Cross-sectional Mothers of infants aged 346/333 Male 81 122 203
201630 study <6 months Female 70 130 200
Total 151 252 403
Setegn et al 2 01131 Oromia, Goba Cross-sectional Mothers with children 668/608 Male 164 152 316
district study (<12 months) Female 150 133 283
Total 314 285 599
Wolde et al 201432 Oromia, Nekemte Cross-sectional Mothers who had 182/174 Male 70 10 80
town study a child less <24 months Female 84 10 94
Total 154 20 174
Woldemichael Oromia, Tiyo Woreda Cross-sectional Mothers who have children 386/373 Male 153 60 213
201633 study <1 year age Female 98 62 160
Total 251 122 373
Continued
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Table 1  Continued 
TIBF
Author/publication Sample size/ Within
year Study area Study design Study population Participated Factors 1 hour After 1 hour Total
Open access

Mekonen et al Amhara, Cross-sectional Mothers of infants 845/823 Male 214 229 443
201834 South Gondar study <12 months Female 187 193 380

Total 401 422 823

B. Antenatal care versus TIBF
Gultie Amhara, Debre Cross-sectional Mothers having children 548/548 ANC 482 88 570
and Sebsibie201635 Berhan town study aged <23 months old No ANC 16 15 31
Total 498 103 601
Tamiru et al 201236 Oromia, Jimma Arjo Cross-sectional Mothers of index children 384/382 ANC 115 69 184
Woreda study aged No ANC 120 71 191
0–6 months
Total 235 140 375
Tamiru SNNPR, Arba Minch Cross-sectional Mothers of infants aged 384/384 ANC 179 140 319
and Tamrat201537 Zuria Woreda study ≤2 years No ANC 40 24 64
Total 219 164 383
Berhe et al 201327 Tigray, Mekelle town Cross-sectional Mothers of children aged 0– 361/361 ANC 263 66 329
study 24 months No ANC 15 13 28
Total 278 79 357
Adugna 201438 SNNPR, Arba Minch Cross-sectional Women who had children 384/383 ANC 179 140 319
Zuria study <2 years No ANC 40 24 64
Total 219 164 383
Beyene et al 201628 SNNPR, Dale Cross-sectional Mothers of children 634/634 ANC 206 58 264
Woreda study <24 months No ANC 311 43 354
Total 517 101 618
39
Derso et al 2017 Amhara, Dabat Cross-sectional Mothers with children 6761/6761 ANC 2135 2220 4355
district study* <5 years of age No ANC 670 1364 2034
Total 2805 3584 6389
Liben and Yesuf Afar, Dubti town Cross-sectional Mothers of infants aged 346/333 ANC 110 196 306
201630 study <6 months No ANC 41 56 97
Total 151 252 403
Continued

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 Table 1  Continued 
TIBF
Author/publication Sample size/ Within
year Study area Study design Study population Participated Factors 1 hour After 1 hour Total
Seid et al 201351 Amhara, Bahir Dar Cross-sectional Mothers who 819/819 ANC 680 94 774
city study delivered in the last No ANC 29 12 41
12 months
Total 709 106 815
Setegn et al 201131 Oromia, Goba Cross-sectional Mothers with children 668/608 ANC 270 238 508
district study (<12 months) No ANC 37 19 56
Total 307 257 564

Habtewold TD, et al. BMJ Open 2019;9:e023956. doi:10.1136/bmjopen-2018-023956

Tewabe 201640 Amhara, Motta town Cross-sectional Mothers with infant 423/405 ANC 282 41 323
study <6 months-old No ANC 37 45 82
Total 319 86 405
Woldemichael Oromia, Tiyo Woreda Cross-sectional Mothers who have children 386/373 ANC 194 41 235
201633 study <1 year age No ANC 57 81 138
Total 251 122 373
Mekonen et al Amhara, Cross-sectional Mothers of infants 845/823 ANC 370 332 702
201834 South Gondar study <12 months
No ANC 31 90 121
Total 401 422 823
*Used nationally representative EDHS data.
ANC, antenatal care; EDHS, Ethiopian Demographic Health Survey; SNNPR, Southern Nations, Nationalities and Peoples' Region ; TIBF, timely initiation of breast feeding.
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Table 2  Characteristics of included studies on EBF

Sample size/ EBF

Author/publication year Study area Study design Study population Participated Factors Yes No Total
A. Gender of newborn versus EBF
Open access

Asemahagn 201642 Amhara, Azezo Cross-sectional Women having 346/332 Male 95 38 133
district study children aged from 0 to Female 167 32 199
6 months
Total 262 70 332
Setegn et al 201243 Oromia, Bale Zone, Cross-sectional Mothers–infant pairs 668/608 Male 107 43 150
Goba district study Female 92 37 129
Total 199 80 279
Sonko and Worku 201544 SNNPR, Halaba Cross-sectional Mothers 422/420 Male 145 60 205
special woreda study with children <6 months Female 151 64 215
of age
Total 296 124 420
Regassa 201425 SNNPR, Sidama Cross-sectional With infants aged 1100/1094 Male 109 19 128
zone study between 0 and 6 Female 89 17 106
months old
Total 198 36 234
26
Alemayehu 2014 Tigray, Axum town Cross-sectional Mothers who had 418/418 Male 97 119 216
study children aged 6–12 Female 77 128 205
months
Total 174 247 421
45
Biks et al 2015 Amhara, Dabat Nested case– All pregnant women 1769/1769 Male 271 619 890
district control study* in the second/third Female 727 1148 1875
trimester
Total 998 1767 2765
Arage and Gedamu 201646 Amhara, Debre Cross-sectional Mothers of infants <6 470/453 Male 119 40 159
Tabor Town study months of age Female 227 67 294
Total 346 107 453
Adugna et al 201747 SNNPR, Hawassa Cross-sectional Mothers with infants 541/529 Male 169 88 257
city study aged 0–6 months Female 153 119 272
Total 322 207 529
Egata et al 201348 Oromia, Kersa Cross-sectional Mothers of children 881/860 Male 323 124 447
district study* <2 years of age Female 294 119 413
Total 617 243 860
Teka et al 201549 Tigray, Enderta Cross-sectional Mothers having children 541/530 Male 158 60 218
Woreda study aged <24 months
Female 214 98 312
Total 372 158 530
Continued

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 Table 2  Continued 

Sample size/ EBF

Author/publication year Study area Study design Study population Participated Factors Yes No Total
50
Sefene 2013 Amhara, Bahir Dar Cross-sectional Mothers who had a 170/159 Male 36 47 83
city study child aged <6 months Female 42 34 76
Total 78 81 159
B. Antenatal care versus EBF
Asemahagn 201642 Amhara, Azezo Cross-sectional Women having 346/332 ANC 243 57 300
district study children aged from 0 to No ANC 19 13 32
6 months
Total 262 70 332
Gultie and Sebsibie 201635 Amhara, Debre Cross-sectional Mothers having children 548/548 ANC 263 253 516
Berhan town study aged <23 months old No ANC 10 21 31
Total 273 274 547
Hunegnaw et al 201752 Amhara, Gozamin Cross-sectional Mothers who had 506/478 ANC 341 109 450
district study infants aged between 6 No ANC 17 11 28
and 12 months
Total 358 120 478
Lenja et al 201653 SNNPR, Offa district Cross-sectional Mothers of infants 403/396 ANC 233 43 276

Habtewold TD, et al. BMJ Open 2019;9:e023956. doi:10.1136/bmjopen-2018-023956

study <6 months No ANC 44 88 132
Total 277 131 408
Seid et al 201351 Amhara, Bahir Dar Cross-sectional Mothers who 819/819 ANC 405 372 777
city study delivered in the last No ANC 7 35 42
12 months
Total 412 407 819
31
Setegn et al 2011 Oromia, Goba Cross-sectional Mothers with children 668/608 ANC 166 65 231
district study (<12 months) No ANC 27 10 37
Total 193 75 268
44
Sonko and Worku 2015 SNNPR, Halaba Cross-sectional Mothers 422/420 ANC 258 88 346
special woreda study with children <6 months No ANC 38 36 74
of age
Total 296 124 420
Tadesse et al 201654 SNNPR, Sorro Cross-sectional Mothers with infants 602/579 ANC 211 121 332
District Study aged 0–5 months No ANC 59 123 182
Total 270 244 514
Tariku et al 201755 Amhara, Dabat Cross-sectional Mothers with children 5227/5227 ANC 1979 1353 3332
District study * aged <59 months
No ANC 713 876 1589
Total 2692 2229 4921
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Continued

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Table 2  Continued 

Sample size/ EBF

Author/publication year Study area Study design Study population Participated Factors Yes No Total
40
Tewabe 2016 Amhara, Motta town, Cross-sectional Mothers with an infant 423/405 ANC 185 164 349
Open access

East Gojjam zone study <6 months old No ANC 18 38 56

Total 203 202 405
Tamiru et al 201236 Oromia, Jimma Arjo Cross-sectional Mothers of index 384/382 ANC 87 103 190
Woreda study children aged No ANC 96 96 192
0–6 months
Total 183 199 382
37
Tamiru and Tamrat 2015 SNNPR, Arba Minch Cross-sectional Mothers of infants aged 384/384 ANC 228 92 320
Zuria Woreda study ≤2 years No ANC 27 37 64
Total 255 129 384
Biks et al 201545 Amhara, Dabat Nested case– All pregnant women 1769/1769 ANC 180 277 457
district control study* in the second/third No ANC 363 949 1312
trimester
Total 543 1226 1769
Abera 201256 Harari, Harar town Cross-sectional Mothers of children 604/583 ANC 194 163 357
study aged <2 years No ANC 13 29 42
Total 207 192 399
Arage and Gedamu 201646 Amhara, Debre Cross-sectional Mothers of infants <6 470/453 ANC 384 39 423
Tabor Town study months of age No ANC 18 12 30
Total 402 51 453
Adugna et al 201747 SNNPR, Hawassa Cross-sectional Mothers with infants 541/529 ANC 221 111 332
city study aged 0–6 months No ANC 101 96 197
Total 322 207 529
Egata et al 201348 Oromia, Kersa Cross-sectional Mothers of children 881/860 ANC 233 135 368
district study* <2 years of age No ANC 384 108 492
Total 617 243 860
57
Taddele 2014 Amhara, Injibara Comparative Employed and 524/473 ANC 90 98 188
Town cross-sectional unemployed mothers of No ANC 6 23 29
study children aged ≤1 year
Total 96 121 217
Echamo 201258 SNNPR, Arbaminch Cross-sectional Mothers of infants 768/768 ANC 332 360 692
town study within the age of 6–12
No ANC 25 51 76
months
Total 357 411 768
Continued

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 Table 2  Continued 

Sample size/ EBF

Author/publication year Study area Study design Study population Participated Factors Yes No Total
49
Teka et al 2015 Tigray, Enderta Cross-sectional Mothers having children 541/530 ANC 325 134 459
Woreda study aged <24 months No ANC 47 24 71
Total 372 158 530
Chekol et al 201759 Amhara, Gondar Cross-sectional Mothers with children 333/333 ANC 131 117 248
town study aged 7–12 months No ANC 29 56 85
Total 160 173 333
C. Postnatal care versus EBF
Asemahagn 201642 Amhara, Azezo Cross-sectional Women having 346/332 PNC 137 25 162
district study children aged from 0 to No PNC 125 45 170
6 months
Total 262 70 332
53
Lenja et al 2016 SNNPR, Offa district Cross-sectional Mothers of infants 403/396 PNC 188 33 221
study <6 months No PNC 121 54 175
Total 309 87 396

Habtewold TD, et al. BMJ Open 2019;9:e023956. doi:10.1136/bmjopen-2018-023956

Sonko and Worku 201544 SNNPR, Halaba Cross-sectional Mothers with children 422/420 PNC 98 25 123
special woreda study <6 months of age No PNC 197 99 296
Total 295 124 419
Tadesse et al 201654 SNNPR, Sorro Cross-sectional Mothers with infants 602/579 PNC 204 127 331
District Study aged 0–5 months No PNC 66 117 183
Total 270 244 514
Tewabe et al 201660 Amhara, Motta town, Cross-sectional Mothers with an infant 423/405 PNC 116 81 197
East Gojjam zone Study <6 months old No PNC 87 121 208
Total 203 202 405
Abera 201256 Harari, Harar town Cross-sectional Mothers of children 604/583 PNC 29 31 60
study aged <2 years No PNC 178 161 339
Total 207 192 399
Teka et al 201549 Tigray, Enderta Cross-sectional Mothers having children 541/530 PNC 167 86 253
woreda study aged <24 months
No PNC 205 72 277
Total 372 158 530
*Used nationally representative EDHS data.
ANC, antenatal care; EBF, exclusive breast feeding; EDHS, Ethiopian Demographic Health Survey; PNC, postnatal care; SNNPR, Southern Nations, Nationalities and Peoples' Region.
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11
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Figure 2  Forest plot of the unadjusted odds ratios with Figure 4  Forest plot of the unadjusted odds ratios with
corresponding 95% CIs of 10 studies on the association of corresponding 95% CIs of 11 studies on the association
gender of newborn and TIBF. The horizontal line represents of newborn gender and EBF. The horizontal line represents
the CI, the box and its size in the middle of the horizontal line the CI, the box and its size in the middle of the horizontal
represents the weight of sample size. The polygon represents line represents the weight of sample size. The polygon
the pooled OR. The reference category is ‘Female’. LIBF,  represents the pooled OR. The reference category is
late  initiation  of breast feeding; REM, random-effects model; ‘Female’. EBF, exclusive breast feeding; NEBF, non exclusive
TIBF, timely initiation of breast feeding. of breast feeding; REM, random-effects model.

Furthermore, seven studies42 44 49 53 54 56 60 reported

who had at least one PNC visit had 86% significantly
the association between EBF and PNC in 2995 mothers
higher chance of exclusively breast feed during the
(table 2C). The pooled OR of PNC was 1.86 (95% CI
first 6 months compared with mothers who had no PNC
1.41 to 2.47, p<0.0001, I2=63.4%) (figure 6). Mothers

Figure 3  Forest plot of the unadjusted odds ratios with Figure 5  Forest plot of the unadjusted odds ratios with
corresponding 95% CIs of 13 studies on the association of corresponding 95% CIs of 21 studies on the association of
ANC and TIBF. The horizontal line represents the CI, the box ANC and EBF. The horizontal line represents the CI, the box
and its size in the middle of the horizontal line represents the and its size in the middle of the horizontal line represents the
weight of sample size. The polygon represents the pooled weight of sample size. The polygon represents the pooled
OR. The reference category is ‘No ANC follow-up’. ANC, OR. The reference category is ‘No ANC follow-up’. ANC,
antenatal care; LIBF, late initiation of breast feeding; REM, antenatal care; EBF, exclusive breast feeding; NEBF, non-
random-effects model; TIBF, timely initiation of breast feeding. exclusive of breast feeding; REM, random-effects model.

12 Habtewold TD, et al. BMJ Open 2019;9:e023956. doi:10.1136/bmjopen-2018-023956

 Open access

Figure 8  Forest plot showing the results from a cumulative

Figure 6  Forest plot of the unadjusted odds ratios with meta-analysis of studies examining the effect of ANC
corresponding 95% CIs of seven studies on the association on TIBF. ANC, antenatal care; TIBF, timely initiation of
of PNC and EBF. The horizontal line represents the CI, the breast feeding.
box and its size in the middle of the horizontal line represents
the weight of sample size. The polygon represents the pooled
OR. The reference category is ‘No PNC follow-up’. EBF,
of ANC (figure 10) and PNC (figure 11) have been
exclusive breast feeding; NEBF, non-exclusive breast feeding;
PNC, postnatal care; REM, random-effects model. increasing.

Meta-regression analysis
In studies reporting the association between TIBF and
follow-up. There was no significant publication bias ANC, 26.29% of the heterogeneity was accounted for the
(z=−0.91, p=0.36) (online supplementary figure 5). variation in study area (region), residence of mothers,
Cumulative meta-analysis sample size and publication year. Based on the omnibus
As illustrated in figure 7, the effect of gender of newborn test of moderators, however, none of these factors influ-
(figure 7) has not been changed whereas the effect of enced association between TIBF and ANC (QM=11.57,
ANC on TIBF (figure 8) has been increasing over time. df=8, p=0.17). In studies reporting the association between
Similarly, the effect of gender of newborn on EBF TIBF and gender of newborn, the estimated amount of
(figure 9) has not been changed over time. The effect total heterogeneity was substantially low (tau2=4.28%);

Figure 7  Forest plot showing the results from a cumulative Figure 9  Forest plot showing the results from a cumulative
meta-analysis of studies examining the effect of gender of meta-analysis of studies examining the effect of gender of
newborn on TIBF. TIBF, timely initiation of breast feeding. newborn on EBF. EBF, exclusive breast feeding.

Habtewold TD, et al. BMJ Open 2019;9:e023956. doi:10.1136/bmjopen-2018-023956 13

Open access

Discussion
This meta-analysis assessed the association between
breastfeeding practices (ie, TIBF and EBF) and gender
of newborn, ANC and PNC. The key findings were EBF
was significantly associated with ANC, PNC and gender of
newborn whereas TIBF was significantly associated with
ANC but not with gender of newborn.
In congruent with our hypothesis and the large body of
global evidence,61–66 our finding indicated that mothers
who had at least one antenatal visit had a significantly
higher chance of initiating breast feeding within 1 hour
of birth and exclusively breast feed for the first 6 months
compared with mothers who had no ANC visit. This may
be because health professionals provide breastfeeding
guidance and counselling during ANC visit.7 The Ethio-
pian Ministry of Health has also adopted Baby-Friendly
Hospital Initiative programme as part of the national
nutrition programme and is now actively working to
Figure 10  Forest plot showing the results from a cumulative integrate to all public and private health facilities and
meta-analysis of studies examining the effect of ANC on improving breastfeeding practice as a result.
EBF. ANC, antenatal care; EBF, exclusive breast feeding.
We also showed that mothers who had at least one
PNC visit had nearly twice higher chance of exclusively
breast feeding during the first 6 months compared with
as a result, it is not relevant to investigate the possible
mothers who had no PNC follow-up. This result supported
reasons for heterogeneity. our hypothesis, and various studies have similarly reported
Among studies reporting the association between EBF a significantly high rate of EBF in mothers who had a
and gender of newborn, ANC and PNC, 77.66%, 60.29% postnatal visit at health institution66 or postnatal home
and 100% of the heterogeneity were accounted for the visit.67 The possible justification could be that postnatal
variation in study area (region), residence of mothers, visit health education may positively influence the belief
sample size and publication year, respectively. Based and decision of the mothers to exclusively breast feed.
on the omnibus test of moderators, study area (region) Previous studies have also shown that postnatal education
and publication year negatively influenced the associ- and counselling are important to increase EBF practice.68
ation between gender of newborn and EBF practice In addition, in our previous meta-analyses, we showed
(QM=18.46, df=7, p=0.01). Study area (region) negatively that guidance and counselling during PNC was signifi-
influenced the association between ANC and EBF prac- cantly associated with high-rate EBF.7 Furthermore, PNC
tice (QM=27.55, df=8, p=0.001) (table 3). may ease breastfeeding difficulty, increase maternal confi-
dence and encourage social/family support which lead
the mother to continue EBF for 6 months.
Finally, in agreement with our hypothesis and previous
studies,69–71 we uncovered gender of newborn was signifi-
cantly associated with EBF practice. Mothers with male
newborn had a 31% significantly higher chance of exclu-
sively breast feeding during the first 6 months compared
with mothers of female newborn. This finding disproved
the traditional perception and belief in Ethiopia that
male newborn has prelacteal feeding to be strong and
healthy compared with female newborn. On the other
hand, several studies63 66 depicted that gender of newborn
is not significantly associated with breastfeeding practice,
such as TIBF as we showed in our meta-analysis. This
discrepancy might be due to the sociocultural difference
and lack of adequate power given that we only found 10
studies to estimate the pooled effect size.
This systematic review and meta-analysis was conducted
based on published protocol,15 and PRISMA guideline for
Figure 11  Forest plot showing the results from a cumulative literature reviews. In addition, publication bias was quan-
meta-analysis of studies examining the effect of PNC on tified using Egger’s regression statistical test and NOS was
EBF. EBF, exclusive breast feeding; PNC, postnatal care. used to assess the quality of included studies. Since it is

14 Habtewold TD, et al. BMJ Open 2019;9:e023956. doi:10.1136/bmjopen-2018-023956

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Table 3  Meta-regression analysis to identify possible factors of heterogeneity among the included studies
Variables (reference category)* Estimate SE Z value P value CI.lb CI.ub
TIBF
ANC
Amhara region (Afar) 1.71 1.17 1.46 0.15 −0.59 4.01
Oromia region (Afar) 1.48 0.91 1.62 0.10 −0.31 3.28
SNNPR region (Afar) 0.54 1.09 0.50 0.62 −1.58 2.67
Tigray region (Afar) 1.58 1.30 1.21 0.23 −0.97 4.12
Urban residence (Rural) 0.71 1.07 0.67 0.51 −1.38 2.80
Urban and rural residence (Rural) 0.65 1.25 0.52 0.61 −1.81 3.10
≥501 mothers (≤500 mothers) −0.54 0.81 −0.66 0.51 −2.13 1.06
Published 2016–2018 (2011–2015) 0.14 0.82 0.17 0.87 −1.47 1.74
EBF
Gender of newborn
Oromia region (Amhara) −0.54 0.24 −2.22 0.03 −1.02 −0.06
SNNPR region (Amhara) 0.12 0.26 0.46 0.64 −0.39 0.63
Tigray region (Amhara) −0.39 0.30 −1.31 0.19 −0.98 0.19
Urban residence (Rural) 0.79 0.51 1.57 0.12 −0.20 1.78
Urban and rural residence (Rural) −0.10 0.44 −0.24 0.81 −0.96 0.75
≥501 mothers (≤500 mothers) 0.78 0.23 3.34 <0.001 0.32 1.24
Published 2016–2018 (2011–2015) −1.14 0.44 −2.59 0.01 −1.99 −0.28
ANC
Harari region (Amhara) −0.11 0.64 −0.17 0.87 −1.37 1.16
Oromia region (Amhara) −1.27 0.39 −3.28 0.001 −2.03 −0.51
SNNPR region (Amhara) 0.09 0.35 0.27 0.78 −0.59 0.78
Tigray region (Amhara) −0.49 0.57 −0.87 0.38 −1.60 0.62
Urban residence (Rural) −0.18 0.38 −0.47 0.63 −0.92 0.56
Urban and rural residence (Rural) −0.26 0.52 −0.49 0.62 −1.28 0.76
≥501 mothers (≤500 mothers) −0.30 0.34 −0.87 0.38 −0.96 0.37
Published 2016–2018 (2011–2015) 0.08 0.28 0.29 0.77 −0.46 0.62
PNC†
Harari region (Amhara) −0.60 0.48 −1.24 0.22 −1.54 0.35
SNNPR region (Amhara) 0.25 0.30 0.82 0.41 −0.34 0.83
Tigray region (Amhara) −0.16 0.64 −0.25 0.80 −1.42 1.10
≥501 mothers (≤500 mothers) 0.11 0.31 0.36 0.72 −0.50 0.73
Published 2016–2018 (2011–2015) 0.26 0.36 0.71 0.47 −0.45 0.96
*Since we do not have a specific hypothesis, the reference category is selected arbitrarily; †Residence is dropped from the model due to small
sample size of included studies. Cut-off  value for sample size and publication year was arbitrarily chosen.
ANC, antenatal care; CI.lb, CI interval, lower bound; CI.ub, CI interval, upper bound; EBF, exclusive breast feeding; PNC, postnatal care;
SNNPR, Southern Nations, Nationalities and Peoples’ Region; TIBF, timely initiation of breast feeding.

the first study in Ethiopia, the evidence could be helpful missing relevant studies cannot be fully exempted and
for future researchers, public health practitioners and the finding may not be nationally representative. Based
healthcare policy-makers. The inclusion of all previously on the conventional method of heterogeneity test, a few
published studies is a further strength of this meta-anal- analyses suffer from high between-study variation. The
ysis. This study has limitations as well. Almost all included course of heterogeneity was carefully explored using
studies were observational, which weakens the strength meta-regression analysis, and this variation may be due
of evidence and hinder causality inference. Even though to the difference in study area (region), residence of
we have used broad search strategies, the possibility of mothers, sample size, publication year or other residual

Habtewold TD, et al. BMJ Open 2019;9:e023956. doi:10.1136/bmjopen-2018-023956 15

 Open access

factors; therefore, the result should be interpreted with 3. Edmond KM, Zandoh C, Quigley MA, et al. Delayed breastfeeding
initiation increases risk of neonatal mortality. Pediatrics
caution. Moreover, the dose–response relationship 2006;117:e380–6.
between the number of ANC or PNC visits and breast- 4. World Health Organization. Infant and young child feeding: model
feeding practices was not examined. Lastly, significant chapter for textbooks for medical students and allied health
professionals. Infant and young child feeding: model chapter for
publication bias was detected in studies that reported the textbooks for medical students and allied health professionals,
association between EBF and gender of newborn. We did 2009.
5. Unicef W. Capture the Moment – Early initiation of breastfeeding: The
Duval and Tweedie trim-and-fill analysis to adjust publica- best start for every newborn, 2018.
tion bias and to provide an unbiased estimate; however, 6. UNICEF. Infant and young child feeding. 2018. Available at https://​
the result should be cautiously interpreted. data.​unicef.​org/​topic/​nutrition/​infant-​and-​young-​child-​feeding/
(Accessed 20 Sep 2018).
7. Habtewold TD, Mohammed SH, Endalamaw A, et al. Breast and
complementary feeding in Ethiopia: new national evidence from
systematic review and meta-analyses of studies in the past 10 years.
Eur J Nutr 2018.
Conclusions 8. Boccolini CS, MLd C. Oliveira, Maria Inês Couto de. Factors
In line with our hypothesis, we found that increasing associated with exclusive breastfeeding in the first six months of life
the use of antenatal and PNC has a positive effect on in Brazil: a systematic review. Rev Saude Publica 2015:49.
9. Sharma IK, Byrne A. Early initiation of breastfeeding: a systematic
breastfeeding practices (ie, TIBF and EBF), which signi- literature review of factors and barriers in South Asia. Int Breastfeed
fies stakeholders would provide emphasis on ANC and J 2016;11:17.
10. Alemu SM, Alemu YM, Habtewold TD. Association of age and
PNC service to optimise breast feeding. This meta-anal- colostrum discarding with breast-feeding practice in Ethiopia:
ysis study provided an overview of up-to-date evidence systematic review and meta-analyses. Public Health Nutr 2019:1–20.
11. Alebel A, Dejenu G, Mullu G, et al. Timely initiation of breastfeeding
for public nutrition professionals and policy-makers and its association with birth place in Ethiopia: a systematic review
in Ethiopia. It could also be useful for breastfeeding and meta-analysis. Int Breastfeed J 2017;12:44.
improvement initiative in Ethiopia and cross-country and 12. Alebel A, Tesma C, Temesgen B, et al. Exclusive breastfeeding
practice in Ethiopia and its association with antenatal care and
cross-cultural comparison. From the research point of institutional delivery: a systematic review and meta-analysis. Int
view, in general, intervention and outcome based studies Breastfeed J 2018;13:31.
13. Temesgen H, Negesse A, Woyraw W, et al. Dietary diversity feeding
on breast feeding in Ethiopia are required. practice and its associated factors among children age 6-23 months
in Ethiopia from 2011 up to 2018: a systematic review and meta-
Author affiliations analysis. Ital J Pediatr 2018;44:109.
1
Department of Nursing, Debre Berhan University, Debre Berhan, Ethiopia 14. Temesgen H, Negesse A, Woyraw W, et al. Prelacteal feeding and
2
Department of Epidemiology, University Medical Center Groningen, University of associated factors in Ethiopia: systematic review and meta-analysis.
Int Breastfeed J 2018;13:49.
Groningen, Groningen, The Netherlands
3 15. Habtewold TD, Islam MA, Sharew NT, et al. SystEmatic review and
Department of Public Health, University Medical Center Groningen, University of meta-aNAlysis of infanT and young child feeding Practices (ENAT-P)
Groningen, Groningen, The Netherlands in Ethiopia: protocol. BMJ Open 2017;7:e017437.
16. Kraemer HC. Kappa coefficient. Wiley StatsRef: Statistics Reference
Acknowledgements  Our special gratitude forwarded to Sjoukje van der Werf Online 2014:1–4.
17. Peterson J, Welch V, Losos M, et al. The Newcastle-Ottawa scale
(University of Groningen, the Netherlands) for her support to develop the search
(NOS) for assessing the quality of nonrandomised studies in meta-
strings and Balewgizie Sileshi (University of Groningen, the Netherlands) for his analyses. 2011.
support during the title and abstract screening. 18. Munn Z, Tufanaru C, Aromataris E. JBI's systematic reviews: data
Contributors  NTS and TDH conceived and designed the study. TDH developed a extraction and synthesis. Am J Nurs 2014;114:49–54.
19. Brinkhoff T. Federal Democratic Republic of Ethiopia. 2015. 2018.
syntax for searching databases, analysed the data and interpreted the results. TDH
Available at http://www.​citypopulation.​de/​Ethiopia.​html.
and SMA wrote and revised the manuscript. All authors read and approved the final 20. Egger M, Davey Smith G, Schneider M, et al. Bias in meta-analysis
manuscript. detected by a simple, graphical test. BMJ 1997;315:629–34.
Funding  The authors have not declared a specific grant for this research from any 21. Duval S, Tweedie R. Trim and fill: A simple funnel-plot-based method
funding agency in the public, commercial or not-for-profit sectors. of testing and adjusting for publication bias in meta-analysis.
Biometrics 2000;56:455–63.
Competing interests  None declared. 22. Higgins JP, Thompson SG. Quantifying heterogeneity in a meta-
analysis. Stat Med 2002;21:1539–58.
Patient consent for publication  Not required. 23. Viechtbauer W. Conducting Meta-Analyses in R with the metafor
Provenance and peer review  Not commissioned; externally peer reviewed. Package. J Stat Softw 2010;36.
24. Moher D, Liberati A, Tetzlaff J, et al. Preferred reporting items for
Data sharing statement  All data generated or analysed in this study are included systematic reviews and meta-analyses: the PRISMA statement. PLoS
in the article and its supplementary files. Med 2009;6:e1000097.
25. Regassa N. Infant and child feeding practices among farming
Open access This is an open access article distributed in accordance with the communities in Southern Ethiopia. Kontakt 2014;16:e215–22.
Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which 26. Alemayehu M. Factors Associated with Timely Initiation and
permits others to distribute, remix, adapt, build upon this work non-commercially, Exclusive Breast Feeding among Mothers of Axum Town, Northern
and license their derivative works on different terms, provided the original work is Ethiopia. Science Journal of Public Health 2014;2:394–401.
properly cited, appropriate credit is given, any changes made indicated, and the use 27. Berhe H, Mekonnen B, Bayray A, et al. Determinants of Breast
is non-commercial. See: http://​creativecommons.​org/​licenses/​by-​nc/​4.​0/. feeding Practices Among Mothers Attending Public Health
Facilities, Mekelle, Northern Ethiopia; A Cross Sectional Study.
International Journal of Pharmaceutical Sciences and Research
2013;4:650.
28. Beyene MG, Geda NR, Habtewold TD, et al. Early initiation
of breastfeeding among mothers of children under the age of
References 24 months in Southern Ethiopia. Int Breastfeed J 2016;12.
1. World Health Organization. Infant and young child feeding: a tool for 29. Lakew Y, Tabar L, Haile D. Socio-medical determinants of timely
assessing national practices, policies and programmes, 2003. breastfeeding initiation in Ethiopia: Evidence from the 2011
2. World Health Organization. Babies and mothers worldwide failed by nation wide Demographic and Health Survey. Int Breastfeed J
lack of investment in breastfeeding. Saudi Med J 2017;38:974–5. 2015;10.

16 Habtewold TD, et al. BMJ Open 2019;9:e023956. doi:10.1136/bmjopen-2018-023956

 Open access

30. Liben ML, Yesuf EM. Determinants of early initiation of breastfeeding City Administration, Northwest Ethiopia; A Community Based
in Amibara district, Northeastern Ethiopia: a community based cross- Cross-Sectional Survey. Science Journal of Clinical Medicine
sectional study. Int Breastfeed J 2016;11. 2013;2:153–9.
31. Setegn T, Gerbaba M, Belachew T. Determinants of timely initiation of 51. Seid AM, Yesuf ME, Koye DN. Prevalence of Exclusive Breastfeeding
breastfeeding among mothers in Goba Woreda, South East Ethiopia: Practices and associated factors among mothers in Bahir Dar city,
a cross sectional study. BMC Public Health 2011;11:217,2458–11- Northwest Ethiopia: a community based cross-sectional study. Int
217. Breastfeed J 2013;8:14.
32. Wolde T, Birhanu T, Ejeta E. Prevalence and determinants of timely 52. Hunegnaw MT, Gezie LD, Teferra AS. Exclusive breastfeeding and
initiation of breastfeeding among lactating mothers of urban dwellers associated factors among mothers in Gozamin district, northwest
in Western Ethiopia: A community based cross sectional study. Food Ethiopia: a community based cross-sectional study. Int Breastfeed J
Science and Quality Management 2014:31. 2017;12.
33. Woldemichael B. Timely Initiation of Breastfeeding and Its Associated 53. Lenja A, Demissie T, Yohannes B, et al. Determinants of exclusive
Factors among Mothers in Tiyo Woreda, Arsi Zone, Ethiopia: A breastfeeding practice to infants aged less than six months in Offa
Community- Based Cross Sectional Study. Clinics in Mother and district, Southern Ethiopia: a cross-sectional study. Int Breastfeed J
Child Health 2016;13:221. 2016;11:32.
34. Mekonen L, Seifu W, Shiferaw Z. Timely initiation of breastfeeding 54. Tadesse T, Mesfin F, Chane T. Prevalence and associated factors of
and associated factors among mothers of infants under 12 months non-exclusive breastfeeding of infants during the first six months
in South Gondar zone, Amhara regional state, Ethiopia; 2013. Int in rural area of Sorro District, Southern Ethiopia: a cross-sectional
Breastfeed J 2018;13:17. study. Int Breastfeed J 2016;11. 25,016-0085-6. eCollection 2016.
35. Gultie T, Sebsibie G. Determinants of suboptimal breastfeeding 55. Tariku A, Alemu K, Gizaw Z, et al. Mothers' education and ANC
practice in Debre Berhan town, Ethiopia: a cross sectional study. Int visit improved exclusive breastfeeding in Dabat Health and
Breastfeed J 2016;11. Demographic Surveillance System Site, northwest Ethiopia. PLoS
36. Tamiru D, Belachew T, Loha E, et al. Sub-optimal breastfeeding of One 2017;12:e0179056.
infants during the first six months and associated factors in rural 56. Abera K. Infant and young child feeding practices among
communities of Jimma Arjo Woreda, Southwest Ethiopia. BMC mothers living in Harar, Ethiopia. Harar Bulletin of Health Sciences
Public Health 2012;12:363,2458–12-363. 2012;4:66–78.
37. Tamiru D, Tamrat M. Constraints to the optimal breastfeeding 57. Taddele M. Exclusive Breastfeeding and Maternal Employment
practices of breastfeeding mothers in the rural communities of Arba in Ethiopia: A Comparative Cross- Sectional Study. International
Minch Zuria Woreda, Ethiopia: a community-based, cross-sectional Journal of Nutrition and Food Sciences 2014;3:497–503.
study. South African Journal of Clinical Nutrition 2015;28:134–9. 58. Echamo M. Exclusive breast feeding in Arbaminch, SNNPR, Ethiopia.
38. Adugna DT. Women's perception and risk factors for delayed Harar Bull Health Sci 2012;5:44–59.
initiation of breastfeeding in Arba Minch Zuria, Southern Ethiopia. Int 59. Chekol DA, Biks GA, Gelaw YA, et al. Exclusive breastfeeding and
Breastfeed J 2014;9. mothers' employment status in Gondar town, Northwest Ethiopia: a
39. Derso T, Biks GA, Tariku A, et al. Correlates of early neonatal feeding comparative cross-sectional study. Int Breastfeed J 2017;12:27.
practice in Dabat HDSS site, northwest Ethiopia. Int Breastfeed J 60. Tewabe T, Mandesh A, Gualu T, et al. Exclusive breastfeeding
2017;12. practice and associated factors among mothers in Motta town,
40. Tewabe T. Timely initiation of breastfeeding and associated factors
East Gojjam zone, Amhara Regional State, Ethiopia, 2015: a cross-
among mothers in Motta town, East Gojjam zone, Amhara regional
sectional study. Int Breastfeed J 2016;12.
state, Ethiopia, 2015: a cross-sectional study. BMC Pregnancy
61. Patel A, Badhoniya N, Khadse S, et al. South Asia Infant Feeding
Childbirth 2016;16:314.
Research Netwoork. Infant and young child feeding indicators and
41. Musa Seid A. Vaginal Delivery and Maternal Knowledge on Correct
determinants of poor feeding practices in India: secondary data
Breastfeeding Initiation Time as Predictors of Early Breastfeeding
analysis of National Family Health Survey 2005-06. Food Nutr Bull
Initiation: Lesson from a Community-Based Cross-Sectional Study.
2010;31:314–33.
ISRN Epidemiology 2014;2014:1–6.
62. Mihrshahi S, Kabir I, Roy SK, et al. South Asia Infant Feeding
42. Asemahagn MA. Determinants of exclusive breastfeeding practices
among mothers in azezo district, northwest Ethiopia. Int Breastfeed J Research Network. Determinants of infant and young child feeding
2016;11. practices in Bangladesh: secondary data analysis of Demographic
43. Setegn T, Belachew T, Gerbaba M, et al. Factors associated with and Health Survey 2004. Food Nutr Bull 2010;31:295–313.
exclusive breastfeeding practices among mothers in Goba district, 63. Senarath U, Dibley MJ, Godakandage SS, et al. South Asia Infant
south east Ethiopia: A cross-sectional study. Int Breastfeeding J Feeding Research Network (SAIFRN)*. Determinants of infant and
2012:7. young child feeding practices in Sri Lanka: secondary data analysis
44. Sonko A, Worku A. Prevalence and predictors of exclusive of Demographic and Health Survey 2000. Food and nutrition bulletin
breastfeeding for the first six months of life among women in Halaba 2010;31:352–65.
special woreda, Southern Nations, Nationalities and Peoples' 64. Ogunlesi TA. Maternal socio-demographic factors influencing the
Region/SNNPR/, Ethiopia: a community based cross-sectional study. initiation and exclusivity of breastfeeding in a Nigerian semi-urban
Arch Public Health 2015;73. setting. Matern Child Health J 2010;14:459–65.
45. Biks GA, Tariku A, Tessema GA. Effects of antenatal care and 65. Okafor IP, Olatona FA, Olufemi OA. Breastfeeding practices of
institutional delivery on exclusive breastfeeding practice in northwest mothers of young children in Lagos, Nigeria. Niger J Paediatr
Ethiopia: a nested case-control study. Int Breastfeed J 2015;10:30. 2014;41:43–7.
46. Arage G, Gedamu H. Exclusive Breastfeeding Practice and Its 66. Subedi N, Paudel S, Rana T, et al. Infant and young child feeding
Associated Factors among Mothers of Infants Less Than Six Months practices in Chepang communities. J Nepal Health Res Counc
of Age in Debre Tabor Town, Northwest Ethiopia: A Cross-Sectional 2012;10:141-6.
Study. Adv Public Health 2016;2016:1–7. 67. Bashour HN, Kharouf MH, Abdulsalam AA, et al. Effect of postnatal
47. Adugna B, Tadele H, Reta F, et al. Determinants of exclusive home visits on maternal/infant outcomes in Syria: a randomized
breastfeeding in infants less than six months of age in Hawassa, an controlled trial. Public Health Nurs 2008;25:115–25.
urban setting, Ethiopia. Int Breastfeed J 2017;12:45. 68. Su LL, Chong YS, Chan YH, et al. Antenatal education and postnatal
48. Egata G, Berhane Y, Worku A. Predictors of non-exclusive support strategies for improving rates of exclusive breast feeding:
breastfeeding at 6 months among rural mothers in east Ethiopia: a randomised controlled trial. BMJ 2007;335:596.
community-based analytical cross-sectional study. Int Breastfeed J 69. Agho KE, Dibley MJ, Odiase JI, et al. Determinants of exclusive
2013;8:8. breastfeeding in Nigeria. BMC Pregnancy Childbirth 2011;11:2.
49. Teka B, Assefa H, Haileslassie K. Prevalence and determinant 70. Ogada IA. Effectiveness of couple counselling versus maternal
factors of exclusive breastfeeding practices among mothers in counselling in promoting exclusive breast feeding: a randomised
Enderta woreda, Tigray, North Ethiopia: a cross-sectional study. Int controlled trial in Nyando District, Kenya. 2014.
Breastfeed J 2015;10:2. 71. Al Ghwass MM, Ahmed D. Prevalence and predictors of 6-month
50. Sefene A. Determinants of Exclusive Breastfeeding Practice exclusive breastfeeding in a rural area in Egypt. Breastfeed Med
among Mothers of Children Age Less Than 6 Month in Bahir Dar 2011;6:191–6.

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