Infant and Young Child Feeding Practice and Associated Factors among 0-23 Old Months of Children in Irrigated and Non-Irrigated Areas of Dangila District, North West of Ethiopia

Abstract

Background: Infant and young child feeding practice is a cornerstone of care for child development both mentally and physically. Failure to implement proper infant and young child feeding practices is associated with an increased risk of childhood morbidity and mortality.

Objective: To assess the prevalence of infant and young child feeding practices among 0-23 months-old children in irrigated and non-irrigated areas of Dangila Woreda, North-west Ethiopia, 2021.

Methods: A community-based comparative cross-sectional study was conducted from Dec 1, 2020 to Jun 1, 2021 with a total of 823 mothers who have infants and young children 0-23 months of age in 9 selected Keebles. A stratified sampling technique was implemented to select irrigated and nonirrigated kebeles and study units. Data was collected by the face-to-face interview method. Bivariate and multivariate analysis were used. Variables with p 0.05 were taken as statistically significant and independently associated with infant and young child feeding practice. An adjusted odds ratio, along with a 95% confidence interval, was used to assess the strength of the association.

Result: Among 823 households visited, 802 participants gave complete responses, a response rate of 97.4%. The overall prevalence of infant and young child feeding practice was 62.56%. Of these, 72.8% (95%CI: 67.5%, 76.1%) from irrigated and 52.2% (95%CI: 47.8%, 57.4%) from non-irrigated areas had good practice of IYCF. Moreover, the study identified that ANC (AOR = 2.138, 95% CI: 1.085, 4.210), knowledge (AOR = 2.43, 95% CI: 0.275, 0.612), attitude (AOR = 1.687, 95% CI: 1.129, 2.520), PNC (AOR = 1.606, 95% CI: 1.154, 2.360) and women’s decision making (AOR = 1.941, 95% CI: 1.305, 2.888) were significant predictors for IYCF among 0-23-months of age children.

Conclusion: The overall prevalence of infant and young child feeding practice in the study area was 62.5 percent, with significant differences between irrigated and non-irrigated areas. Infant and young child feeding practices are high as compared to previous studies. Women’s decision making, ANC follow up, PNC follow up, attitude, and knowledge were identified as the intervention areas.

Keywords: Dangila district; Irrigated kebele; Non-irrigated kebele; IYCF practice

Abbreviations

AMIYCN: Adolescent, Maternal, Infant, and Young Child Nutrition; ANC: Antenatal Care; CF: Complementary Feeding; EBF: Exclusive Breast Feeding; EDHS: Ethiopian Demographic and Health Survey; EIBF: Early initiation of Breast Feeding; EMDHS: Ethiopian Mini-Demographic and Health Survey; GDP: Gross Domestic Production; HSTP: Health Sector Transformation Plan; IYCF: Infant and Young Child Feeding; MAD: Minimum Acceptable Diet; MDD: Minimum Dietary Diversity; MDG: Millennium Development Goal; MMF Minimum Meal Frequency; NICU: Neonatal Intensive Care Unit; NNP: National Nutrition Program; PNC: Postnatal Care; HH: Household

Introduction

A collection of principles for establishing optimal infant and young child feeding practices in children aged 0 to 23 months is known as baby and young child feeding [1]. Early initiation of breastfeeding, exclusive breastfeeding, continuous nursing until the child reaches the age of two, and timely, adequate, and safe complementary feeding (CF) and consumption of iron-rich foods are all important markers of IYCF practice [2]. Breastfeeding should begin within one hour of birth and continue exclusively throughout the first six months of a child’s life, up to and including two years of age. Starting at 6 months, breastfeeding should be supplemented with age-appropriate solid, semi-solid, and soft food feedings [3]. Breast milk is a healthy food since it contains all of the essential nutrients as well as anti-infective components that prevent diarrhea and pneumonia [4]. To protect the newborn from disease and death, breastfeeding should begin within one hour of birth. Breastfeeding enhances an infant’s immune system and may help them avoid chronic diseases later in life, such as obesity and diabetes. Breastfeeding also protects women from certain cancers and other illnesses. Appropriate feeding begins at six months of age and helps to prevent malnutrition as well as the spread of infectious diseases like diarrhea and pneumonia [3,5]. A infant who is not exclusively breastfed has a substantially higher risk of contracting diarrhea or pneumonia than one who is [3].

IYCF practice is a cornerstone of care for child development mentally and growth physically, but it is often under estimated. Failure to proper infant and young child feeding practice is associated with increased risks of child health. Such as childhood morbidity, mortality impaired motor, cognitive and behavioral development, slow physical growth, diminished immunity, reduced learning capacity and under-nutrition [6]. Poor nutrition leads to ill-health and ill-health contributes to further deterioration in nutritional status. 50-70% of the burden of diarrheal diseases, measles, malaria and lower respiratory infections was attributable to malnutrition [7,8].

According to the World Health Organization (WHO) and the United Nations International Children’s Fund (UNICEF), newborns should be nursed exclusively for the first six months of their lives, with appropriate complementary feeding after that. Breastfeeding can be continued for up to two years or longer [9]. To encourage healthy feeding practices, the Ethiopian Ministry of Health (MOH) established the national nutrition program (NNP II) and the national guideline on adolescent, maternal, infant, and young child nutrition (AMIYCN). It has been decided to ramp up community-based nutrition programs and nutrition-sensitive activities. Increasing access to potable water and expanding medium and large irrigation projects, for example, could assist increase productivity and vary the foods produced throughout the year [10-12]. For example, extending medium and large irrigation projects and increasing access to potable water could help enhance output and diversify the foods produced throughout the year [10-12].

Ethiopia has witnessed encouraging progress in improving IYCF practice over the past decade by developing polices and strategies to support IYCF practice. However, IYCF practice remains so poor. Moreover under-nutrition is one of the main culprits causing high child mortality, accounting half of all childhood deaths in Ethiopia that the country must continue to make significant investments from nutrition again [12].

Statement of the problem

Globally 10.6 million children under 5 years die every year. Of this mortality malnutrition accounts about 53% of deaths to underfives children in developing countries [13]. Out of world’s underfive children, 162 million stunted [14], 101 million underweight and 52 million were wasted [14]. Of the estimated 162 million stunted children, 90 percent are found in Africa and Asia, one of which is Ethiopia. In Sub-Saharan Africa the prevalence of stunting, wasting and underweight were 57.7%, 18% and 28.8% respectively [15]. Similarly in Ethiopia, 37%, 7% and 21% of children under-five years were stunted, wasted and underweight respectively; while in Amhara stunting was 46% [4]. The magnitude also extends to study area stunting; wasting and underweight were 40.74%, 9.6% and 24.4% respectively [16].

The issue of IYCF practice is widespread; it is estimated that 50% and 34.8 percent of newborns are EIBF and EBF for the first 6 months of their lives, respectively. Complementary foods are sometimes introduced too early or too late, and they are frequently nutritionally deficient and dangerous [5,17,18]. Surprisingly, only 18% of children were fed a minimum acceptable diet (MAD), 28% were fed a variety of foods, and 55% were fed with a minimum meal frequency (MMF) [3]. It is well acknowledged that Africa has a large problem, with EBF, MMF, and MDD each accounting for 51%, 37-40%, and 40% of the total [7,19,20]. In Sub-Saharan Africa, less than 35%, 60%, and 18% of children aged 6-23 months satisfied the MDD, MMF, and MAD criteria, respectively [21]. In Ethiopia, 32.2% of newborn and young child feeding practices were adequate for all variables, but only 7% were appropriate supplemental feeding practices [7,22,23].

According to the 2019 Mini Demographic and Health Survey, EIBF and EBF were 73 percent and 59 percent, respectively, in Ethiopia (EMDHS).

According to the survey, only 7% of MAD sufferers and 14% of MDD sufferers In contrast to WHO recommendations for IYCF, 14% of infants aged 0 to 5 months drink plain water and 13% drink complementary foods in addition to breast milk. Notably, only 6% of infants under the age of six months are breastfed at all. Only 9% of infants under the age of 6 months use a bottle with a nipple, a practice that is discouraged due to the risk of infecting the child [24].

WHO and UNICEF collaborated on the Global Strategy for IYCF Practice. It underlines the importance of healthy newborn and child feeding practices in increasing nutritional status and reducing infant mortality in all countries (9). Globally, malnutrition is being combated by implementing sustainable development goals. The National Nutrition Strategy (NNS) and the Health Sector Transformational Plan (HSTP) have been approved by Ethiopia’s government to tackle malnutrition, particularly among children under the age of five. The Ethiopian government has vowed to end child malnutrition by launching the ‘Seqota Declaration’ [6]. Appropriate IYCF feeding has a fundamental importance for human survival, growth, development, health and nutrition to prevent morbidity and mortality significantly from under-five children [5,25]. It also improves nutritional status, which reduces poverty and stimulates economic growth to achieve health, education, employment goals and physical productivity of the labor force [26]. While poor IYCF practice is the principal proximate causes of malnutrition during the first two years of life. The cycle of early nutritional deficits are linked to malnourished girl child faces greater odds of giving birth to a malnourished and low birth weight infant when she grows up [1,12,27]. Globally, hunger and under nutrition reduce gross domestic product by US$1.4-2.1 trillion a year and losing more than 10% of their lifetime earning potential, thus affecting national productivity [28,29]. The total annual cost of under nutrition in Ethiopia was estimated at Ethiopian Birr (ETB) 55.5 billion, equivalent to 16.5% of Gross Domestic Product (GDP) [30]. Eliminating under nutrition in Ethiopia would prevent losses of 8–11% per year from the gross national product [31].

The low prevalence and poor practice of infant and young child feeding practice in most developing countries including Ethiopia are attributed to various socio-demographic, maternal and child health related factors. Such as residence, maternal age, age of the child, maternal occupation, educational status of mother, access to mass media, place of delivery, mode of delivery, knowledge, attitude, HH food security status, women’s decision making and economic status. Those factors are associated with IYCF practice positively or negatively according to studies were identified [7,22,23,32-34].

Different literatures, governmental and non-governmental reports argue that, IYCF practice is not well practiced globally and nationally [9,35,36]. Even these realities in Ethiopia, there were few studies were conducted to identify the prevalence and associated factors among children less than 2yrs [32,37,38]. However, most of those studies were conducted in urban area, which is difficult to generalize the findings to rural area and comparative cross-sectional study designs were not implemented. Important variables like house hold food security and attitude were not included. More over the evidence in irrigated and non-irrigated area is scarce or limited. This indicates that, it has a long way to go to fill these gaps. Therefore, the aim of this study is to compare infant and young child feeding practice among 0-23 months of age in irrigated and non-irrigated area.

Methods

Study design and period

A Community based comparative cross-sectional study was conducted from Dec 1, 2020 to Jun 1, 2021.

Study area and population

The study was conducted in Dangila district, which was found in Awi zone located 485 Km from the capital city Addis Ababa and 78Km from regional city Bahir Dar. In the district there were Amhara and Agew elites with a total projected population of 156169 in the year 2020. It is further divided into 6 sub clusters and 31 kebeles. In Dangila district, there are 1 primary hospital (governmental), 6 Health Centers and 31 health posts. The district childbearing age groups were 34825 of the total female population and under-five age groups were 21145 among these under-two years were 7808 [75]. Out of 31 kebeles, 10 kebeles were irrigation practiced and 21 kebeles were non-irrigation practiced.

Source population

The source populations for the study were all mothers who had infant and young children 0-23 months of age residing in Dangila, Woreda.

Study population

The study populations were all mothers who had infant and young children 0-23 months of age in the selected kebeles.

Study unit

All selected mothers who had infant and young children 0-23 months of age in each selected kebeles.

Inclusion criteria

Mothers who had infant and young children 0-23 months of age in the selected kebeles were included in the study.

Operational definition of terms

Irrigated area: Areas where a practice to river diversion, pumping, and small or large dam’s for agricultural cultivation during non-rainfall seasons in addition to rainfall seasons [76].

Non-irrigated area: Areas where agricultural cultivation practice is only during rainfall seasons [76].

Appropriate IYCF practice/good: Defined as early initiation of breast feeding within1hr after delivery, exclusive breast feeding to infant age less than 6 months, continue breast feeding 1yrs and above, timely introduction of solid, semi-solid and soft foods in 6-8 months of age, minimum dietary diversity, minimum meal frequency, minimum acceptable diet and consumption of Iron rich foods. A practice that was appropriate for a specific age group received a score of 1, and a practice that was inappropriate received a score of 0. If summed score of the indicators is equal to 4 or above (above mean), it was considered as appropriate (good) IYCFP and If summed score of the indicators is equal to 3 or below ( below mean), it was considered as inappropriate(good) IYCFP [2,23].

Early initiation of breastfeed: Proportion of children born in the last 23 months who were put to the breast within one hour of birth [77].

Exclusive breastfeeding (EBF): Means that an infant receives only breast milk from his or her mother or a wet-nurse, or expressed breast milk, and no other liquids or solids, not even water, with the exception of oral rehydration solution, drops or syrups consisting of vitamins, minerals supplements or medicines [5,77].

Continued breastfeeding: Continue breastfeeding for to 1yrs and above or more along with complementary feeding.

Introduction of complementary feeding: The process of introducing, solid, semi-solid or soft foods along with breast milk 6-8 months, when breast milk is no longer sufficient to meet the nutritional requirements of infants and young children [5].

Minimum dietary diversity: Proportion of children 6-23 months of age who receive foods from 4 or more food groups among the 7 food groups [77].

Minimum meal frequency: Proportion of breastfed and nonbreastfed children 6-23 months of age who receive solid, semi-solid, or soft foods (but also including milk feeds for non-breastfed children. minimum frequency by age defined as: - 2 times for breastfed infants 6-9 months, 3 times for breastfed children 9-24 months and 4 times for non-breastfed children 6-24 months. In this study the maximum value 4 was taken to compute meal frequency [77].

Minimum acceptable diet: Proportion of children 6-23 months of age who receive a mini- mum dietary diversity and minimum meal frequency (apart from breast milk) [77].

Consumption iron rich foods: Proportion of children 6-23 months of age who receive iron rich foods [77].

Knowledgeable of IYCF: When the respondents correctly answer above mean of questions about IYCF knowledge [38].

Less knowledgeable of IYCF: When the respondents correctly answer below mean of questions about IYCF knowledge [38].

Positive attitude about IYCF: When the respondents agree to favorable questions to appropriate IYCF [38].

Negative attitude about IYCF: When the respondents disagree and don’t know to favorable questions to appropriate IYCF [38].

Wealth Index: Is a composite measure of the cumulative living standard of a household.

House hold food security: A state in which “all people at all times have both physical and economic access to sufficient food to meet their dietary needs for a productive and healthy life”. Measured by asking in the past four week’s household food status using yes or no questions. 0 = No (skip to Q---) 1 = Yes (1 = rarely (once or twice in the past four weeks, 2 = Sometimes (three to ten times in the past four weeks, 3 = Often (more than ten times in the past four weeks).

Calculate the household food Insecurity access category for each household. 1 = Food Secure, 2=Mildly Food Insecure Access, 3=Moderately Food Insecure Access, 4=Severely Food Insecure Access [78].

Women’s decision making: Participation of women’s from HH decision making with their husband. In this study the measurement was by taking three No=0, yes=1 question from DHIS, among these questions the cumulative result=3 women’s decision and 1, 2= no women’s decision making.

Sample size determination

Sample size estimation of the study followed two approaches considering the two objectives. For the first objective, sample size was calculated using double population proportion formula by considering the following assumptions: 95% confidence interval, 80% power, and prevalence IYCF practice in irrigated area (p1), prevalence IYCF practice in non-irrigated area (p2). The two comparison groups population ratio 1:1, prevalence of infant and young child feeding practice (p2=43.4%) was taken from the previous studies done at North Achefer Woreda, Amhara, Ethiopia [38]. For irrigated area the prevalence of infant and young child feeding (p1=53.4%) was taken to detect 10 % difference from non-irrigated area. Therefore, n1=n2=391, the group sample was 782 and using the correction formula, so the total sample size was 823 (including the 5% nonresponse rate).

Sampling procedure

Dangila Woreda had a total of 31 kebeles. Stratified random sampling method was implemented to identify irrigated and nonirrigated kebeles. After stratification three kebeles from irrigated and six kebeles from non-irrigated were selected by using simple random sampling technic lottery method. Proportion to size allocation was used to determine the required sample size from each selected Kebeles. The sample was taken by using systematic simple random sampling technique from the list of infant and young children registration at health post. Finally select the study participants until that a total of 823 mothers who had infant and young children 0-23 months of age fulfill.

Instrument and data collection procedure

Questioner was prepared after reviewing different literature developed for similar purposes by different authors. The questioner was developed in English then translated in to local language (Amharic) and finally retranslated back to English to check its consistency. The questionnaire was containing socio-demographic and economic, house hold food security, Knowledge and attitude related factors and maternal, child health service related factors and women’s decision making.

Data was collected by using face-to-face interview method. The data collection was conducted in a private and calm environment to ensure confidentiality. The data collectors were four diploma nurses and the supervisor was one health officer. A total of 30 days was taken for data collection period from Dec 8, 2020 to Jun 8, 2021.

Data quality assurance

The quality of the data was ensured by using a well-designed questionnaire adapted from previous literature, EDHS, and various guidelines. The principal investigator also provided training for both data collectors and supervisors on the purpose of the study, data collection technique, and proper questioner filling for two days as another data quality assurance method. Pretesting was used to control data quality; pretesting was done on 5% of the samples in adjacent kebeles from Chara to check the quality of the questionnaire and the instrument prior to actual data collection with similar socio-demographic characteristics. Every day following data collection, the principal investigator reviewed questionnaires to ensure completeness of questions. Incomplete questionnaires were removed from consideration. The data collection process was closely monitored by the principal investigator and the supervisor. Before data entry, the completeness of the questioner was also cheeked, and the data was coded, entered, and stored in the computer using Epiinfo data version 7, then exported to SPSS statistical software version 23.

Data processing, analysis and presentation

Descriptive analysis was used in the study to describe the percentage and number of respondents by socio demographic characteristics and other relevant variables.

To investigate the relationship between independent variables and dependent variables, bivariate logistic regression analysis was performed on the independent variables, and their proportion and crude odds ratio were computed against the outcome variable to identify the factors that will be associated with the dependent variables.

Those variables with a p-value of 0.25 that showed an association with the outcome variables in the bivariate analysis were entered into the final logistic regression to control for potential confounders.

The Hosmer-Lemshow goodness of fit test was used to assess the model’s fitness. To assess the strength of the association, an adjusted odds ratio (AOR) with a 95 percent confidence interval was calculated, and a P value less than 0.05 was considered significant.

Results

Socio-demographic characteristics

Among the 823 households visited, 802 respondents provided complete responses, with a response rate of 97.8 percent in irrigated areas and 96.11 percent in non-irrigated areas. 276 (68%) and 263 (66.4%) of study participants had children aged 6-23 months in irrigated and non-irrigated areas, respectively. The children’s mean(SD) age was 10.61(6.1) months, and the mothers’ mean age was 30.3 (6.2) years. In terms of mother’s educational status, 213 (52.5%) and 182 (46%), respectively, of mothers in irrigated and nonirrigated areas had no formal education. Almost all of the participants in this study, 395 (98%) in the irrigated area and 391 (98.74%) in the non-irrigated area, were orthodox Christian followers. Wealth index status of households 209(51.48%) and 134(33.8%) had higher asset of household economy among irrigated and non-irrigated Areas, respectively (Table 1).