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Abstract

Background:

This study aimed to determine the prevalence of colostrum avoidance and identify its associated factors among mothers of infants under 6 months in Chiro District, Eastern Ethiopia.

Methods:

A community-based cross-sectional study was conducted among mothers with children under 6 months. Poisson regression was employed to identify variables associated with colostrum avoidance, considering an adjusted prevalence ratio (APR) with a 95% confidence interval, and a P-value of less than .05 for statistical significance.

Results:

The study found a colostrum avoidance prevalence of 14.1% (95% CI: 11.8-16.6). Significant factors associated with avoidance included home delivery (APR = 1.8; 95% CI: 1.1-2.3), lack of postnatal care (APR = 2.1; 95% CI: 1.4-2.7), delayed breastfeeding initiation beyond 1 hour (APR = 1.6; 95% CI: 1.1-2.2), and inadequate knowledge about colostrum (APR = 2.2; 95% CI: 1.1-2.9).

Keywords

colostrum avoidance practices mothers children under 6 months Eastern Ethiopia

Introduction

Colostrum, the first milk produced in the initial days postpartum, is characterized by its yellow hue and rich nutritional profile.¹ This early secretion is abundant in essential nutrients and bioactive compounds critical for the health and growth of neonates.² Supporting colostrum feeding is a vital public health intervention aimed at improving infant and child health outcomes.³ Despite its importance, the avoidance of colostrum feeding has emerged as a significant contributor to respiratory and diarrheal diseases during infancy.⁴

A study in Pakistan involving over 17 000 children revealed a strong association between inadequate breastfeeding practices and increased neonatal and infant mortality.⁵ In Sub-Saharan Africa, where breastfeeding rates are among the lowest globally, the region also experiences the highest under-five mortality rates.⁶ Notably, delayed breastfeeding initiation is linked to a threefold risk of under-five mortality.⁷ A systematic review and meta-analysis highlighted a pooled prevalence of colostrum avoidance practices in Ethiopia at 19.07%, with individual studies reporting rates ranging from 6.8% in Aksum, Tigray,⁸ to 22.1% in Bure District.⁹

The Sustainable Development Goals (SDG) 2030 agenda aims to significantly reduce preventable deaths among newborns and children under 5, targeting a mortality rate of 12 per 1000 live births.^10,11 Adequate nutrition during infancy is crucial for the overall well-being of children, as their growth, health, and development are largely influenced by early nutritional status and immunity.¹² Despite the numerous health benefits of colostrum feeding, its avoidance remains prevalent across diverse cultural contexts, particularly in developing countries like Ethiopia.^13
-15 Various traditional beliefs and cultural practices contribute to this avoidance.^14
-16

Research conducted in Ethiopia has identified socio-demographic factors, knowledge, attitudes, health-seeking behaviors, counseling, and obstetric-related factors as significant determinants of colostrum avoidance practices.^8,9,17
-19 Given the high prevalence of colostrum avoidance in Ethiopia, this study aims to assess the extent of this practice and identify the factors influencing mothers’ decisions regarding colostrum feeding. The findings will provide valuable insights to inform policies and interventions designed to promote optimal breastfeeding practices and enhance infant health in the region. Therefore, this study aimed to determine the prevalence of colostrum avoidance and identify its associated factors among mothers of infants under 6 months in Chiro District, Eastern Ethiopia.

Methods and Materials

Study Setting

This study was conducted in the Chiro District, located in the West Hararghe Zone of Eastern Ethiopia, approximately 326 km from the capital city, Addis Ababa. The district encompasses 39 rural and 3 urban kebeles. According to the 2007 census, the projected population of Chiro town in 2023 is 272 340, with 133 656 females. The urban population accounts for approximately 45 043 residents. Healthcare infrastructure in the Chiro District includes 1 public hospital, 1 health facility, 3 health posts, and 9 private clinics. In total, there are 5 private clinics, 39 health posts, and 7 health centers within the woreda. During the study period, the number of mothers with children under 6 months was recorded at 2108.

Study Design and Population

A community-based cross-sectional study was conducted in the Chiro District from September 1 to September 30, 2023. The source population comprised all mothers residing in the district who had children under 6 months of age. Eligible participants included mothers who had lived in the Chiro District for more than 6 months. Mothers who were critically ill and unable to respond to interview questions were excluded from the study during the data collection period.

Sampling and Sampling Procedure

The sample size was determined using a formula for estimating a single population proportion. Key assumptions included a prevalence of colostrum avoidance practices among mothers of children under 6 months in Bure District, estimated at 44.4%,⁹ with a 95% confidence interval, a margin of error of 3% (d = 0.03), a design effect of 1.5, and a non-response rate of 10%. This resulted in a total sample size of 875. This higher, more conservative prevalence was selected to ensure a sufficient sample size and maximize the power of the study.

A multistage sampling technique was employed to select study units from the community. Chiro Woreda consists of 42 kebeles (39 rural and 3 urban). From these, 6 rural kebeles and 1 urban kebele were randomly selected using simple random sampling. In each selected kebele, households with mothers who had children under 6 months were identified through house-to-house visits conducted by data collectors and community health extension workers (CHEWs). The calculated sample size of 875 was then proportionally allocated to each kebele.

Finally, participants were selected using systematic random sampling, with every second household chosen (K = 2). This was calculated as follows: K = N/n = 2108/875, yielding K = 2.4, which approximated to 2. The first participant was selected using a lottery method.

Study Variables and Measurements

The dependent variable in this study was colostrum avoidance practices. Independent variables included socio-demographic characteristics, maternal obstetric and medical-related factors, and breastfeeding-related characteristics.

Operational Definitions

Colostrum Avoidance

The act of avoiding or discarding colostrum at least once within the first 3 days following the delivery of the newborn.²⁰

Knowledge About Colostrum

Knowledge was assessed based on the mean score from 8 questions covering the nutritional and immunological benefits of colostrum.²¹

Attitudes Toward Colostrum Feedings

Participants who scored at or above the mean on attitude-related questions regarding colostrum feeding were deemed to have a favorable attitude, while those with lower scores were categorized as having an unfavorable attitude.²¹

Prelacteal Feeding

The provision of any fluids or foods to neonates, excluding drugs, vitamins, minerals, and vaccines, before the initiation of breastfeeding or within the first few days of life after delivery.²²

Data Collection Tool and Procedures

Data were collected using a pretested, semi-structured, interviewer-administered questionnaire adapted from various literature sources.^9,21,23 The original tool was developed in English, then translated into the national languages (Afan Oromo and Amharic), and subsequently back-translated into English by a second individual to ensure consistency.

The Afan Oromo and Amharic versions of the questionnaire were utilized for data collection. The tool encompassed sections on socio-demographic information, maternal health services, obstetric-related characteristics, and breastfeeding-related factors.

For the data collection process, 8 BSc midwifery professionals with experience in community data collection were recruited. They were supervised by 4 nurse professionals holding master’s degrees to ensure the integrity and accuracy of the data collected.

Data Quality Control

Data collectors and supervisors underwent a 2-day training conducted by the principal investigator, which covered the study’s objectives and data collection methodologies. A pretest was administered to 5% of the sample size (44 participants) in Gelemso town, which was not part of the actual study. Continuous follow-up and supervision were maintained by the supervisors throughout the data collection period to ensure adherence to protocols and data quality.

Data Analysis

Data were coded, cleaned, and entered into Epi Data version 3.1 software before being exported to Stata version 17 for analysis. Descriptive results were reported as frequencies, percentages, means, and standard deviations. The associations between independent factors were examined using the Poisson regression analysis model with robust variance estimation. This approach mitigates convergence issues commonly encountered with binomial data and provides a more accurate prevalence ratio, particularly when the dependent variable is frequent and has a prevalence exceeding 10%.

To assess multicollinearity among explanatory variables, the variance inflation factor (VIF) and correlation matrix for regression coefficients were employed, confirming the absence of collinearity. The final model was selected based on Akaike’s Information Criterion (AIC) and Bayesian Information Criterion (BIC). Model fit was evaluated using the Pearson Chi-square test and the Hosmer-Lemeshow goodness-of-fit test. Results were reported as adjusted prevalence ratios (APRs) with 95% confidence intervals (CIs); P-values of less than 0.05 were considered indicative of statistically significant associations.

Ethical Approval and Informed Consent

The ethical approval was obtained from the Institutional Health Research Ethics Review Committee of College of Health and Medical Sciences, Haramaya University IHRERC/132/2023. First, a supportive letter was written to the Woreda administration from Haramaya University. Then, permission was obtained from Woreda administration and supportive letters were written to each Kebele. Participants in the study gave their written consent before data were collected. Throughout the research, data confidentiality was maintained. Furthermore, this study included no intrusive procedures and was carried out according to the Helsinki Declaration.

Results

Socio-Demographic Characteristics of Participants

A total of 850 mothers with children under 6 months of age were interviewed, yielding a response rate of 97.1%. Among the respondents, 374 mothers were aged between 23 and 29 years, with a mean age of 29.4 years (standard deviation ± 7.41), and their ages ranged from 16 to 49 years. Approximately 284 mothers (33.4%) had attended secondary school, while 463 (54.5%) were rural residents (Table 1).

Table 1.

Socio-demographic characteristics of mothers of infants under 6 months in Chiro District, Oromia Region, Eastern Ethiopia, 2023 (n = 850).

Variables	Frequency	Percent (%)
Age of participant (years)
<23	94	11.0
23-29	374	44.0
30-38	276	32.5
≥39	106	12.5
Maternal educational level
No formal education	139	16.4
Primary	268	31.5
Secondary	284	33.4
Diploma and above	159	18.7
Maternal household head
Yes	333	39.2
No	517	60.8
Maternal occupation
Unemployed	190	22.4
Employed	660	77.6
Infant sex
Male	398	46.8
Female	452	53.2
Religion
Muslim	266	31.3
Orthodox	333	39.2
Protestant	177	20.8
Others^a	74	8.7
Residence of participant
Rural	463	54.5
Urban	387	45.5

Indicates that (Adventist, Wakefata, and Catholic).

Obstetric and Medical-Related Characteristics

In this study, 617 participants (72.6%) were multiparous women, and 786 mothers (92.5%) had at least 1 antenatal care contact during their current pregnancy. A total of 663 mothers (78.0%) delivered their index child at health institutions. Among the participants, 778 mothers (91.5%) had spontaneous vaginal deliveries, and 687 mothers (80.8%) reported a history of postnatal care utilization. Additionally, 108 mothers (12.7%) had a chronic disease, while 97 mothers (11.4%) experienced neonatal illness (Table 2).

Table 2.

Obstetric and medical-related characteristics of mothers of infants under 6 months in Chiro District, Oromia Region, Eastern Ethiopia, 2023 (n = 850).

Variables	Frequency	Percent (%)
Parity
Primi-paraous	233	27.4
Multiparous	617	72.6
Anti-natal care contact for current pregnancy
Yes	786	92.5
No	64	7.5
Anti-natal care contact times (n = 786)
1	21	2.7
2	53	6.7
3	166	21.1
≥4	546	69.5
Place of delivery for current birth
Health institution	663	78.0
Home	187	22.0
Mode of delivery
Vaginal	778	91.5
C/S	72	8.5
PNC service utilization
Yes	687	80.8
No	163	19.2
Neonatal illness
No	753	88.6
Yes	97	11.4
Maternal chronic disease
No	742	87.3
Yes	108	12.7

Breastfeeding Related Characteristics

Among the study respondents, 548 mothers (64.5%) of children under 6 months were counseled about breastfeeding at least once by healthcare providers during their current pregnancy or delivery. A total of 672 participants (79.1%) initiated breastfeeding within 1 hour of delivery, and 688 mothers (80.9%) did not practice prelacteal feeding for their current birth. Additionally, 724 mothers (85.2%) demonstrated good knowledge about colostrum feeding (Table 3).

Table 3.

Breastfeeding-related characteristics of mothers of infants under 6 months in Chiro District, Oromia Region, Eastern Ethiopia, 2023 (n = 850).

Variables	Frequency	Percent (%)
Counseled on breastfeeding for the current birth
Yes	548	64.5
No	302	35.5
Breastfeeding initiation time
Within 1 hour	672	79.1
After 1 hour	178	20.9
Pre-lacteal feeding
No	688	80.9
Yes	162	19.1
Type of pre-lacteal feedings (n = 162)
Plain water	44	27.2
Fresh butter	29	17.9
Cow milk	67	41.4
Honey	12	7.4
Tea	10	6.1
Reason for pre-lacteal feeding (n = 162)
Delayed initiation	22	13.6
Cultural practices	49	30.2
Inadequate breast secretion	49	30.2
Maternal illness	42	26.0
Cultural support of colostrum feeding
Yes	743	87.4
No	107	12.6
Husband support of colostrum avoidance
No	619	72.8
Yes	231	27.2
Knowledge of colostrum
Good	724	85.2
Poor	126	14.8
An attitude of colostrum feeding
Favorable	438	51.5
Unfavorable	412	48.5

Prevalence of Colostrum Avoidance

The prevalence of colostrum avoidance practices among mothers with children under 6 months of age in Chiro District, Oromia Region, Eastern Ethiopia, was 14.1% (120 out of 850) with a 95% confidence interval of 11.8% to 16.6% (Figure 1).

Figure 1.

Colostrum avoidance practices of mothers of infants under 6 months in Chiro District, Oromia Region, Eastern Ethiopia, 2023 (n = 850).

Factors Associated with Colostrum Avoidance

Bivariate Poisson regression analysis revealed several factors significantly associated with colostrum avoidance practices among mothers with children under 6 months. These factors included being under 23 years of age, not being the head of the household, not having had antenatal care (ANC) contact, being multiparous, delivering at home, not utilizing postnatal care services, experiencing neonatal illness, initiating breastfeeding after 1 hour, practicing prelacteal feeding, having poor knowledge about colostrum feeding, and lacking husband support for colostrum feeding.

After adjusting for confounding variables, the prevalence of colostrum avoidance practices was found to be 1.8 times higher (APR = 1.8; 95% CI: 1.1, 2.3) among mothers who delivered at home compared to those who delivered in health facilities. Additionally, mothers who did not utilize postnatal care services had a prevalence of colostrum avoidance practices that was 2.1 times higher (APR = 2.1; 95% CI: 1.4, 2.7) than those who did utilize postnatal care. Mothers who initiated breastfeeding after 1 hour were 1.6 times more likely to practice colostrum feeding avoidance compared to those who initiated breastfeeding within 1 hour (APR = 1.6; 95% CI: 1.1, 2.2). Furthermore, mothers with poor knowledge about colostrum feeding were 2.2 times more likely to avoid colostrum compared to those with good knowledge (APR = 2.2; 95% CI: 1.1, 2.9; Tables 4 and 5).

Table 4.

The intermediate models (I-III) of factors associated with colostrum avoidance among mothers of infants under 6 months in Chiro District, Oromia Region, Eastern Ethiopia, 2023 (n = 850).

Variables	Model I APR (95% CI)	Model II APR (95% CI)	Model III APR (95% CI)
Age
Below 23	0.27 (0.10, 1.35)
23-29	Ref
30-38	0.91 (0.67, 1.35)
≥39	0.82 (0.45, 1.49)
Maternal household head
Yes	Ref
No	1.35 (0.91, 2.01)
Antenatal care contact
Yes		Ref
No		0.70 (0.30, 1.10)
Parity
Primi-parous		Ref
Multiparous		1.65 (1.00, 2.46)
Place of delivery
Health institution		Ref
Home		2.50 (1.90, 3.00)
PNC service utilization
Yes		Ref
No		2.20 (1.00, 2.80)
Neonatal illness
No		Ref
Yes		0.82 (0.50, 1.35)
Breastfeeding initiation time
Within 1 hour			Ref
After 1 hour			1.80 (1.20, 2.30)
Pre-lacteal feeding
No			Ref
Yes			1.82 (1.11, 2.72)
Knowledge of colostrum
Good			Ref
Poor			2.80 (1.30, 3.20)
Husband support for colostrum avoidance
No			Ref
Yes			1.65 (1.11, 2.23)

‘Ref’ indicates the Reference category of variables. Model 0: Crude; Model I: Adjusted for socio-demographic characteristics of mothers; Model II: Adjusted for obstetric and medical-related characteristics; Model III: Adjusted for breastfeeding-related characteristics; Model IV: Fully adjusted.

Abbreviations: PR, prevalence ratio; APR, adjusted prevalence ratio.

Table 5.

Factors associated with colostrum avoidance among mothers of infants under 6 months in Chiro District, Oromia Region, Eastern Ethiopia, 2023 (n = 850).

Variables	Crude PR with (95% CI)	Model IV APR (95% CI)	P-value
Age
Below 23	0.27 (0.10, 0.74)	0.91 (0.30, 2.46)	.125
23-29	Ref	Ref
30-38	0.91 (0.67, 1.35)	0.91 (0.61, 1.35)	.065
≥39	0.82 (0.45, 1.49)	0.74 (0.41, 1.49)	.111
Maternal household head
Yes	Ref	Ref
No	1.35 (0.91, 2.01)	1.22 (0.82, 1.82)	.078
Antenatal care contact
Yes	Ref	Ref
No	2.00 (1.70, 2.40)	0.50 (0.00, 0.90)	.060
Parity
Primi-parous	Ref	Ref
Multiparous	1.35 (0.91, 2.01)	1.00 (0.61, 1.65)	.825
Place of delivery
Health institution	Ref	Ref
Home	3.00 (2.50, 3.50)	1.80 (1.10, 2.30)	.001***
PNC service utilization
Yes	Ref	Ref
No	2.30 (1.70, 2.90)	2.10 (1.40, 2.70)	.001**
Neonatal illness
No	Ref	Ref
Yes	0.50 (0.37, 0.82)	0.91 (0.55, 1.65)	.098
Breastfeeding initiation time
Within 1 hour	Ref	Ref
After 1 hour	3.00 (2.50, 3.50)	1.60 (1.10, 2.20)	.001**
Pre-lacteal feeding
No	Ref	Ref
Yes	2.10 (1.70, 2.40)	1.35 (0.82, 2.01)	.102
Knowledge of colostrum
Good	Ref	Ref
Poor	3.1 (2.6, 3.5)	2.2 (1.1, 2.9)	.001**
Husband’s support for colostrum avoidance
No	Ref	Ref
Yes	1.30 (0.90, 1.60)	1.35 (0.91, 2.01)	.068

‘Ref’ indicates the reference category of variables. Model 0: Crude; Model I: Adjusted for socio-demographic characteristics of mothers; Model II: Adjusted for obstetric and medical-related characteristics; Model III: Adjusted for breastfeeding-related characteristics; Model IV: Fully adjusted.

Abbreviations: PR, prevalence ratio; APR, adjusted prevalence ratio.

**indicates factors with P-value <.01, and ***indicates factors with P-value <.001.

Discussion

Colostrum avoidance remains a prevalent practice in Ethiopia, despite its critical importance for child survival.²⁴ This study found that 14.1% (95% CI: 11.8-16.6) of mothers practiced colostrum avoidance, indicating a need for behavioral modification programs targeting colostrum feeding practices among newly delivered mothers. These findings align with studies conducted in Nepal (16.5%),²⁵ Bure District (14.5%),⁹ and Gozamen District, Ethiopia (16.6%),²⁶ but are lower than those reported in India (92%),²⁷ Meshenti town (32.8%),²⁸ and Afar, Northeast Ethiopia (39.5%).²⁹ Conversely, the prevalence is higher than that found in Jinka town (9.8%)¹⁹ and Sodo Zuria District (8.5%).³⁰ These variations may be attributed to differing socio-cultural practices, beliefs, and taboos influencing colostrum avoidance, as well as disparities in maternal health service access (including postnatal care, institutional delivery, and breastfeeding counseling) and geographical location.

The study also identified home delivery as significantly associated with colostrum avoidance practices, consistent with findings from studies in India,²⁷ Bure District,⁹ Gozamen District,²⁶ and Aksum town.⁸ The rationale might be that mothers who deliver at home are likely a proxy for lower access to health education and a higher likelihood of adhering to traditional practices.

Postnatal care service utilization was significantly associated with colostrum avoidance practices, corroborating findings from Aksum town⁸ and Chencha Zuria District.³¹ During postnatal care visits, healthcare providers can counsel mothers on the importance of colostrum feeding, increasing the likelihood that they will practice it.

Late initiation of breastfeeding was another variable linked to colostrum avoidance. Mothers who began breastfeeding after 1 hour were 1.6 times more likely to discard colostrum compared to those who initiated within an hour. This is consistent with studies from Gozamen district,²⁶ Raya Kobo district,³² and Kombolcha town,³³ and may be attributed to the extended time gap between delivery and breastfeeding initiation.

Finally, the current study demonstrated that maternal knowledge about breastfeeding significantly impacts colostrum avoidance practices, aligning with findings from Aksum town,⁸ Bure district,⁹ and Raya Kobo district.³² Mothers lacking awareness of the benefits of colostrum feeding may choose to avoid it. Therefore, raising maternal awareness through health extension workers is crucial for improving knowledge about the benefits of colostrum feeding.

Strengths and Limitations of the Study

This study used a larger sample size, which improved the study participants’ representation and the generalizability of findings. However, there are notable limitations. The information was obtained through self-reporting during interviews, which may be subject to recall bias. Additionally, the absence of qualitative data to support the quantitative findings is another limitation. Addressing these issues in future research could provide a more nuanced understanding of colostrum avoidance practices.

Conclusions

This study revealed that nearly 1 in 7 mothers with children under 6 months practice colostrum avoidance. Significant factors associated with colostrum avoidance included home delivery, lack of postnatal care service utilization, breastfeeding initiation after 1 hour, and poor knowledge about colostrum feeding. Therefore, healthcare workers in the Woreda should promote institutional deliveries, encourage the use of postnatal care services, advocate for breastfeeding initiation within 1 hour, and enhance maternal knowledge about the benefits of colostrum feeding.

Footnotes

Acknowledgements

We would like to express our gratitude to Haramaya University, the data collectors, supervisors, study participants, and community health extension workers for their invaluable contributions to this study.

ORCID iD

Lemesa Abdisa

Ethical Considerations

Ethical clearance was obtained from the Institutional Health Research Ethics Review Committee (IHRERC) of Haramaya University College of Health and Medical Sciences on May 26, with reference number IHRERC/132/2023.

Consent to Participate

A support letter was subsequently issued to the Chiro Woreda Administration. Informed consent was obtained from participants after explaining the benefits and potential harms. There was no mention of patients’ names in the data collection format, which helped keep the confidentiality of information.

Consent for Publication

Not applicable.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

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