Genetu et al.

International Breastfeeding Journal (2017) 12:21

DOI 10.1186/s13006-017-0113-1

RESEARCH Open Access

Breastfeeding counseling and support are

associated with continuous exclusive
breastfeeding from one week to six months
of age among HIV exposed infants in north
Gondar zone, Ethiopia: a cross-sectional
study
Haregeweyin Genetu1, Melaku Kindie Yenit2 and Amare Tariku3*

Abstract
Background: Globally, exclusive breastfeeding prevents 1.3 million child deaths and has an added benefit for
people living with the Human Immune Deficiency Virus (HIV) by preventing mother-to-child transmission of HIV.
However, literature is scarce in Ethiopia; therefore this study aimed to assess the rate of continuous exclusive
breastfeeding from the end of the first week to 6 months of age, among HIV exposed infants (aged 7–20 months)
who were followed up in government hospitals of North Gondar Zone, Ethiopia, and associated factors.
Methods: An institutional based cross-sectional study was conducted from February 21 to March 30, 2016. All
mother-child pairs (367) attending the chronic HIV care clinic in government hospitals of North Gondar Zone were
included in the study. Exclusive breastfeeding was defined as the practice of feeding only breast milk (including
expressed breast milk) during the first 6 months and no other liquids and solid foods except medications. However
since prelacteal feeding is a deep rooted norm in the study setting, we report continuous exclusive breastfeeding
from the end of first week to 6 months of age of infants, ignoring all prelacteal feeding offered at birth. A binary
multivariable logistic regression analysis was employed to identify factors associated with exclusive breastfeeding.
Results: The overall prevalence of continuous exclusive breastfeeding among HIV exposed infants was 86.4%.
According to the multivariable analysis; breastfeeding counseling (Adjusted Odds Ratio [AOR] = 5.1, 95% Confidence
Interval [CI] 1.4, 18.2), breastfeeding support (AOR = 3.7, 95% CI 1.3, 10.5), and not experiencing obstetric problems
(AOR = 3.4, 95% CI: 1.3, 8.8) were associated with higher odds of continuous breastfeeding.
Conclusions: In this study, most HIV exposed infants were continuously breastfed from the end of first week to
6 months of age. Breastfeeding counseling, breastfeeding support and experiencing obstetric problems were identified
as significant determinants of continuous breastfeeding. Therefore, breastfeeding counseling and support should be
strengthened to improve the coverage of optimal exclusive breastfeeding practice. Moreover, prompt diagnosis and
treatment of obstetric problems should be initiated.
Keywords: Continuous exclusive breastfeeding, Exposed infants, Breastfeeding counseling, Breastfeeding support, Ethiopia

* Correspondence: [email protected]
3
Department of Human Nutrition, College of Medicine and Health Sciences,
Institute of Public Health, University of Gondar, Gondar, Ethiopia
Full list of author information is available at the end of the article

© The Author(s). 2017 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and
reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to
the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver
(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
Genetu et al. International Breastfeeding Journal (2017) 12:21 Page 2 of 8

Background In Ethiopia about 1.5% of adults (15–49 years) are

Breastfeeding is an essential child survival intervention HIV positive and the prevalence is higher among women
and provides immunological, psychological, and socio- (1.9%) [19]. To reduce the risk of mother-to-child trans-
economic benefits [1–3]. Globally, exclusive breastfeed- mission of HIV and AIDS related child mortality, the
ing prevents 1.3 million child deaths [4]. In the era of country designed a guideline which advocates exclusive
the Human Immune Deficiency Virus (HIV) pandemic, breastfeeding for the first 6 months, though the practice
breastfeeding is considered as a source of mother-to- remains sub-optimal [20–22, 27]. Exclusive breastfeeding
child transmission of HIV [1, 5, 6]. As a result, the among HIV positive mothers is not well investigated; the
World Health Organization (WHO) advised mothers in- available studies have been conducted on urban dwellers
fected with HIV to avoid breastfeeding if they were able [20, 22, 27], while poorer child feeding practice, lower
to afford and safely prepare formula milk [7]. However, literacy rate and maternal health care utilization are doc-
mindful of the growing evidence supporting the benefits umented in the rural inhabitants [19]. Therefore this
of EBF, the WHO now recommends HIV positive mothers study aimed to determine the prevalence of continuous
to exclusively breastfed their infant’s for 6 months, and to exclusive breastfeeding and associated factors from the
take antiretroviral drugs throughout the breastfeeding end of first week to 6 months of age among HIV ex-
period and until the child is 12 months of age, to reduce posed infants (7–20 months) who had follow up in gov-
the risk of HIV transmission [6–9]. ernment hospitals of North Gondar Zone, Ethiopia.
In spite of this fact, not exclusively breastfeeding con-
tinues as a global public health problem, and only 39%
of infants are exclusively breastfed [10, 11]. In particular, Methods
mixed feeding is still practiced as the norm in develop- Study setting and design
ing countries, and it is found to increase the risk of child An institutional based cross-sectional study was con-
deaths from under-nutrition, diarrhea, pneumonia and ducted from 21 February to 30 March 2016 in the three
other morbidities [10]. There is a marked regional vari- hospitals of North Gondar Zone, northwest Ethiopia.
ation; about 24–80% of infants exposed to HIV are ex- The zone has 126 health centers and 6 hospitals provid-
clusively breastfed in Africa [11–18]. According to the ing health services to the community. Among the total
Ethiopian Demographic and Health Survey (EDHS) six hospitals in the study area, only three (Metema
Report (2011), about 51% of mothers practice EBF [19]. Hospital, Dabark Hospital and Gondar University Hospital)
However, some improvements are observed among HIV are currently providing Anti-Retro Viral Treatment (ART)
infected mothers, and the prevalence of EBF is modest and Prevention of Mother to Child Transmission (PMTCT)
in Addis Ababa [20] and West Oromia (68 and 72%, re- of HIV services. A total of 392 HIV infected mothers with
spectively) [21], while it is highest in Gondar (89.5%) children aged 7–20 months were registered for HIV care
[22] and Mekele (90%) [11]. However, the prevalence of and support.
exclusive breastfeeding in Southern Ethiopia is even
lower than the national average of 48% [7].
Studies have demonstrated that exclusive breastfeeding Sample size and sampling procedure
affected by various factors. The mother’s age [20], know- All HIV positive mothers who had a child aged be-
ledge on the benefit of exclusive breastfeeding [12, 23], tween 7 and 20 months and attended the chronic
occupation [7, 12, 20, 22], urban or rural residence [24], HIV care clinic were the population under study.
lack of education [20], income [20], and the high cost of Mother-child pairs were recruited from the three
formula milk [13] are some the sociodemographic fac- public hospitals providing HIV care in North Gondar
tors significantly associated with exclusive breastfeeding. Zone. The sample size was calculated using Epi-Info
It is also strongly related to the level of maternal health- version 3.7 by considering the following assumptions;
care utilization and morbidities, accordingly the mode the prevalence of EBF among HIV exposed infants
and place of delivery [18, 20, 22, 25], prenatal [20] and was 68% [20], 95% level of confidence, 5% margin of
postnatal healthcare utilization [20], receiving infant error, and 10% non-response rate. Finally, the mini-
feeding counseling [20, 25, 26], breastfeeding support mum sample size of 367 was obtained. To employ
[20, 22], facing obstetric complications and other ma- the systematic random sampling technique, a sam-
ternal morbidities [20, 25] and history of infant illness pling fraction (Kth = N/n) was computed by dividing
in the first 6 months [20, 27] are correlated with the total number of mother-child pairs enrolled for
EBF. Among the psychosocial determinants, fear of HIV care in the three hospitals to the total sample
stigma and discrimination [9, 14, 25] and use of size, and it was 1.07. As a result, all eligible mother-
herbal medicines [25] are inversely related with exclu- child pairs attending the hospitals during the study
sive breastfeeding. period were included consecutively.
Genetu et al. International Breastfeeding Journal (2017) 12:21 Page 3 of 8

Data collection procedure Eleven questions were used to determine the mother’s
A structured interviewer-administered questionnaire was Infant and Young Child Feeding (IYCF) knowledge.
used to collect data. To maintain consistency, the ques- Mothers were asked about the modes of mother to child
tionnaire was first translated from English to Amharic transmission of HIV, benefit of breastfeeding, timely ini-
(the native language of the study area) and was retrans- tiation of breastfeeding, colostrum feeding and it’s health
lated to English by professional translators and Public benefit, optimal duration of exclusive breastfeeding,
Health experts. Six clinical nurses as data collectors and timely initiation of complementary feeding, type of food
two health officers as supervisors were recruited for the to start complementary feeding, how to feed a child and
study. Two days intensive training regarding the object- optimal duration of continued breastfeeding. Using
ive of the study, confidentiality of information, and tech- Principal Component Analysis (PCA), the factor scores
niques to conduct interview was given to the data were summed and ranked to terciles as lowest, medium
collectors and supervisors. and highest. Likewise, the household wealth status was
To address the ethical issues, the data collectors were computed using a composite indicator for urban and
recruited among the permanent employees of the re- rural residents by considering household assets and size
spective hospitals. The data collectors might be prone to of agricultural land. PCA was performed to define the
commit social desirability bias, and efforts were made to household wealth status into lowest, middle and highest.
equip the data collectors with techniques to minimize Data were entered into Epi-Info version 3.5.3 and
this risk. Accordingly, all the study participants were in- exported to Statistical Package for Social Sciences (SPSS)
formed about the objective of the study. The study was version 20 for further analysis. Data cleaning was done
not aimed to evaluate their adherence to counseling and by running frequencies. Descriptive statistics, including
treatment, and their response would not affect their frequencies and proportions were computed to summarize
treatment. Moreover, data collectors created a conducive variables. A binary logistic regression model was fitted.
environment by keeping the mothers apart and making Both bivariable and multivariable logistic regression ana-
them comfortable during data collection. For a few lyses were done, and variables with a p-value of < 0.2 in the
mothers who faced difficulties in remembering the right bivariable analysis were subjected to the multivariable ana-
time of cessation of EBF, data collectors carried out dif- lysis. Both Crude Odds Ratio (COR) and Adjusted Odds
ferent probing mechanisms to help them to recall, Ratio (AOR) with a 95% Confidence Interval (CI) were
thereby minimizing recall bias. Relating the time of initi- estimated to show the strength of association. A p-value of
ation of additional (complementary) food to known pub- < 0.05 was used to identify variables that showed statistical
lic events and immunization schedules were some of the significance in the multivariable analysis.
probing techniques used by data collectors.
The questionnaire was also piloted on 5% of the total Results
sample out of the study area and the acceptability and A total of 367 mother-child pairs were included in the
applicability of the procedures and tools were evaluated study. The mean (± Standard Deviation, SD) age of the
during pretest. mothers and the children was 31.3 (±4.4) years and 12.9
(±4.1) months, respectively. In this study, about three-
Data analysis and study variables fourths of the mothers (74.9, 77.7 and 82.3%, respect-
According to the WHO criteria, exclusive breastfeeding ively) were married, urban inhabitants, and aged 20–35
is defined as the practice of feeding only breast milk years. Nearly half (44.8%) of mothers were outdoor
(including expressed breast milk) during the first workers (Table 1).
6 months and no other liquids and solid foods except A substantial proportion (96.5%) of mothers had at
medications [28]. Accordingly, we asked mothers the least one antenatal care visit, of which 94.6% were coun-
question “When did you first introduce any solid, semi- seled about EBF. Almost all (97.3%) of respondents gave
solid, or fluid (including water) to [child’s name] in birth at healthcare institutions; and cesarean-section de-
addition to breast milk”. However, prelacteal feeding is livery was reported by 21.5%. About 47.4% of mothers
widely practiced in the study area [19]. Therefore, using had an obstetric problem (Table 2). Despite efforts to
a lifelong indicator would underestimate the proportion prevent mother-to-child transmission of HIV, about
of infants being exclusively breastfed. We decided to ex- 1.9% of exposed infants were HIV positive. All (100%) of
cluded anything given to the infant in the first 2–3 days the HIV infected children were from mothers who did
of life (prelacteal feeding) [29]. Therefore, this study de- not receive any breastfeeding support and gave birth vir-
termined the continuous exclusive breastfeeding period ginally. A higher proportion of HIV infection was noted
from the end of first week to 6 months of age among among children who were given prelacteal feeds, whose
HIV exposed infants (aged 7–20 months) who had fol- mothers were illiterate (71.4%) and who experienced an
low up in government hospitals of North Gondar Zone. obstetric problem (57.1%) (Table 3).
Genetu et al. International Breastfeeding Journal (2017) 12:21 Page 4 of 8

Table 1 Sociodemographic and economic characteristics of HIV Table 1 Sociodemographic and economic characteristics of HIV
positive mothers with children aged 7 to 20 months attending positive mothers with children aged 7 to 20 months attending
public hospitals in North Gondar Zone, Ethiopia, 2016 (n = 367) public hospitals in North Gondar Zone, Ethiopia, 2016 (n = 367)
Variables Frequency Percentage (Continued)
Child sex Paternal education
Male 193 52.6 Illiterate 48 13.1
Female 174 47.4 Literate 319 86.9
Child age Maternal employment
7–12 months 185 50.4 Employeeb 96 26.2
13–20 months 182 49.6 Housewife 166 45.2
a
Mean (± SD) age 12.9(±4.1) months Outdoor workers 105 28.6
Maternal age Paternal employment
20–35 years 302 82.3 Employeeb 149 40.6
36–43 years 65 17.7 Outdoor workersa 218 59.4
a
Mean ± SD for mothers was 31.3(±4.4) years Merchants and daily laborers
b
Governmental and non-governmental employees
Number of parity c
single, divorced, and widowed
1–3 325 88.6
4–6 42 11.4 The study demonstrated that, about 86.4% (95% CI:
Number of under five children
82.9, 89.9%) of HIV exposed infants were continuously
exclusively breastfed from the end of first week to
1 242 65.9
6 months of age. Two-thirds (72.8%) of mothers initiated
>1 125 34.1 breastfeeding within an hour of delivery, and about
Family size 79.6% of infants were given colostrum. However, prelac-
≤5 269 73.3 teal feeding was given to 19.1% of infants (Table 4).
>5 98 26.7 Both bivariable and multivariable analyses were done
Residence
to identify factors associated with continuous exclusive
breastfeeding. Accordingly, the result of bivariable ana-
Urban 285 77.7
lysis noted that counseling about exclusive breastfeeding,
Rural 82 22.3 colostrum feeding, experiencing an obstetric problem,
Marital status decision to breastfeed, breastfeeding support, place of
Currently married 275 74.9 delivery, and infant illness were significantly associated
Currently unmarried c
92 25.1 with the practice of continuous exclusive breastfeeding.
Religion
However, only breastfeeding support, breastfeeding coun-
seling, and experiencing an obstetric problem remained
Orthodox 296 80.7
significantly and independently associated with exclusive
Muslim 52 14.2 breastfeeding in the multivariable analysis. Consequently,
Protestant 19 5.1 the odds of continuous EBF were higher among HIV in-
Ethnicity fected mothers who received prenatal EBF counseling
Amhara 286 77.9 (AOR = 5.1; 95% CI: 1.4, 18.2) compared to those who did
Kemant 62 16.9
not receive counseling. Similarly, obtaining breastfeeding
support (AOR = 3.7, 95% CI: 1.3, 10.5) and not experien-
Tigre 12 3.3
cing an obstetric problem (AOR = 3.4, 95% CI: 1.3, 8.8)
Oromo 7 1.9 were associated with increased odds of mothers with a
Wealth status continuous exclusive breastfeeding practice (Table 5).
Poor 122 33.3
Medium 130 35.4 Discussion
Rich 115 31.3
Exclusive breastfeeding has been considered as one of
the proven child survival interventions [10, 30]. Ethiopia
Maternal education
has adopted these established facts and set a target to
Illiterate 110 30 improve EBF to 70% by 2020 [31]. This study showed
Literate 257 70 that, the prevalence of continuous EBF among infants
exposed to HIV was 86.4% which was higher than the
Genetu et al. International Breastfeeding Journal (2017) 12:21 Page 5 of 8

Table 2 Healthcare utilization and morbidity related characteristics Table 2 Healthcare utilization and morbidity related characteristics
of HIV positive mothers with children aged 7 to 20 months of HIV positive mothers with children aged 7 to 20 months
attending public hospitals in North Gondar Zone, Ethiopia, attending public hospitals in North Gondar Zone, Ethiopia,
2016 (n = 367) 2016 (n = 367) (Continued)
Variables Frequency Percentage Spouse 261 71.1
Antenatal care visit Family 219 59.6
Yes 354 96.5 Community 16 4.4
No 13 3.5 Friend 53 14.4
Number of antenatal care visits Others 32 8.4
1–3 72 20.3 Postnatal care
≥4 282 79.7 Yes 266 72.5
Counseling about infant feeding No 101 27.5
Yes 317 89.5 History of infanthood morbidity
No 37 10.5 Yes 120 32.7
Counseling about exclusive breastfeeding No 247 67.3
Yes 347 94.6 Healthcare access
No 20 5.4 ≤2 h 233 63.5
Place of delivery >2 h 134 36.5
Health institution 357 97.3 Breastfeeding support received
Home 10 2.7 Yes 317 90.6
Gestational age No 33 9.4
Preterm 1 0.2 Source of breastfeeding support
Term 357 97.3 Spouse 251 68.4
Post term 9 2.5 Family 286 78.8
Mode of delivery Community c
1 0.3
Spontaneous vaginal 174 47.4 Friends 85 23.2
Assisted vaginal delivery 114 31.1 Health professionals 222 60.5
Cesarean section 79 21.5 Mothers decide to breastfeed
History of obstetrics problem Yes 325 88.6
Yes 174 47.4 No 42 11.4
No 193 52.6 a
Others-pregnancy induced hypertension and acute febrile illness
b
Type of obstetric problem disclose their HIV status for more than one person
c
Support from different people
Prolonged labor 138 79.3
Ante partum hemorrhage 14 8.0
national target. The finding was also consistent with
Postpartum hemorrhage 20 11.6 other reports from Ethiopia: Gondar (89.5%) [22] and
Othersa 2 1.1 Mekele (90%) [31]. This might be related to the context-
Breast problem ual similarities in maternal healthcare utilization among
Yes 45 12.3 study settings.
However, the prevalence of continuous EBF was higher
No 322 87.7
than what was reported from Addis Ababa (68%) [20],
Child weight
Southern Ethiopia (48%) and West Oromia (72%) [21].
2.5–3.0 kg 222 60.5 The observed discrepancy might be attributed to efforts
>3.0 kg 110 30.0 made by the government in promoting the optimal child
Not recorded 35 9.5 feeding practice for HIV infected mothers mainly in the
Disclosing HIV status PMTCT, exposed infant, and ART clinics [32, 33]. Like-
wise, the finding was higher than the reports of other
Yes 309 84.2
developing countries, such as India (44%) [34], Tanzania
No 58 15.8
(24–46%) [16], Kenya (80.4%) [15], Ghana (60%) [13]
For whom HIV status disclosedb and Nigeria (61%) [14]. This is probably due to the fact
Genetu et al. International Breastfeeding Journal (2017) 12:21 Page 6 of 8

Table 3 Distribution of child HIV status by the selected maternal Table 4 Breastfeeding practice of children aged 7 to 20 months
characteristics in North Gondar Zone public hospitals, Ethiopia attending public hospitals in North Gondar Zone, Ethiopia, 2016
Variables HIV status of the child (n = 367)
Positive # (%) Negative # (%) Variables Frequency Percentage
Prelacteal feeding Continuous exclusive breastfeeding

Yes 4 (57.1) 66 (18.3) Yes 317 86.4

No 3 (42.9) 294 (81.7) No 50 13.6

Mother’s education Ever breastfed

Illiterate 5 (71.4) 105 (29.2) Yes 352 95.9

Literate 2 (28.6) 255 (70.8) No 15 4.1

Counseling about exclusive Reasons for not breastfeeding (n = 15)

breastfeeding Shortage of breast milk 2 13.3
Yes 0 (0) 347 (96.4) Mother was busy 7 46.7
No 7 (100.0) 13 (3.6) Not willing to breastfeed 2 13.3
Mode of delivery Health problem of the mother 3 20
Vaginal delivery 7 (100.0) 167 (46.4) Health problem of the child 1 6.7
Othersa 0 (0) 193 (43.6) Colostrum given
History of obstetric problem Yes 292 79.6
Yes 4 (57.1) 170 (47.2) No 75 20.4
No 3 (42.9) 190 (42.8) Prelacteal feeding
a
Cesarean section and instrumental delivery
Yes 70 19.1
that, there is higher cultural acceptability of breastfeed- No 297 80.9
ing in this study area. Furthermore, the difference in Type of prelacteal food givena
EBF practice could be related to the variations in the Butter 8 11.4
study design. The later studies employed a cohort study Plain water 25 35.7
design and ascertained exclusive breastfeeding practice
Sugar with water 40 57.1
prospectively [15, 34], while this study measured EBF
retrospectively using a cross-sectional study design. Abeshb 11 15.7
Therefore, the increased prevalence of EBF in the Traditional medicine 7 10
current study could be related to the retrospective ascer- Frequency of breastfeeding per day
tainment of the EBF practice [29]. ≥8 times 317 90.1
The result of the adjusted analysis showed that, the <8 times 35 9.9
odds of continuous exclusive breastfeeding were higher
Initiation of breastfeeding
among mothers who received prenatal EBF counsel-
ing. The finding was supported by reports elsewhere Within 1 h 254 72.8
[14, 17, 26, 35, 36]. In fact, birth preparedness and After 1 h 95 27.2
breastfeeding counseling are important components of Mothers IYCF knowledge
prenatal care, and the repeated visits also help to Good 136 37
bring the intended maternal behavioral change to- Medium 132 36
wards the optimal breastfeeding practice. The impact
Poor 99 27
of prenatal care mainly operates through the role of a
Multiple responses
clinicians in providing the correct and up-to-dated b
Abesh is made from a roosted fenugreek which is powdered, fermented, and
IYCF information to the mothers [35, 37]. In Ethiopia, im- diluted with water
plementation of the urban Health Extension Program
steps-up utilization of antenatal care, which creates an with the report from Addis Ababa [20]. The possible ex-
extra benefit in bringing the promotive health planation might be attributed to the psychological effects
services, including breastfeeding counseling to the of obstetric problems, such as depression, lack of confi-
household level [30, 38]. dence or worry leading to delayed initiation of breast-
Similarly, the higher odds of continuous exclusive feeding. In fact, the delayed initiation of breastfeeding
breastfeeding were reported among mothers who had no was found to negatively affect the duration of EBF [39].
history of obstetric problems. The finding was consistent Moreover, when mothers encountered obstetrics problems,
Genetu et al. International Breastfeeding Journal (2017) 12:21 Page 7 of 8

Table 5 Factors associated with continuous EBF among HIV attributed to difference in the maternal health care
positive mothers with children aged 7 to 20 months attending utilization, in which almost all of the mothers had
public hospitals in North Gondar Zone, Ethiopia, 2016 (n = 367) antenatal and postnatal follow up, and gave birth in a
Variables EBFa CORb (95% CI) AORc (95% CI) healthcare facility. However in most of the above
Yes No study settings, utilization of maternal health services
Counseling about EBF is sub-optimal.
Yes 304 43 3.8 (1.4,10.1) 5.1 (1.4, 18.2)** The study tried to show the exclusive breastfeeding
practice in a wider study area, particularly including the
No 13 7 1 1
rural residents. However, it was not free from some of
History of obstetric problem
the limitations. Consequently, recall bias and social de-
Yes 137 37 1 1 sirability bias are the possible limitation of the study.
No 180 13 3.7 (1.9,7.3) 3.4 (1.3, 8.9)**
Decision to BF Conclusions
Yes 290 35 4.6 (2.2,9.5) 1.6 (0.5,5.2) In this study, a high proportion of HIV exposed infants
No 27 15 1 1
were exclusively breastfed from the end of first week to
6 months of age. Breastfeeding counseling, breastfeeding
Support to BF
support and experiencing an obstetric problem were the
Yes 288 30 6.6 (3.3,13.1) 3.7 (1.3,10.5)** key factors associated with continuous exclusive breast-
No 29 21 1 1 feeding. Therefore, intensifying breastfeeding counseling
History of infanthood illness and support is essential to improve exclusive breastfeed-
Yes 100 32 1 1 ing practices. Moreover, prompt diagnosis and treatment
No 217 18 3.9 (2.1,7.2) 1.45 (0.6,3.6)
of obstetric problems should be encouraged.
Colostrum given Abbreviations
AIDS: Acquired immune deficiency syndrome; ANC: Antenatal care; AOR: Adjusted
Yes 262 30 3.5 (1.8,6.5) 1.92 (0.7,5.3)
odds ratio; ART: Antiretroviral treatment; CI: Confidence interval; HIV: Human
No 55 20 1 1 immune deficiency virus; IYCF: Infant young child feeding; PMTCT: Prevention of
Mother To Child Transmission; SPSS: Statistical package for social sciences;
Place of delivery WHO: World Health Organization
Health institution 312 45 1 1
Acknowledgment
home 5 5 0.14 (0.1,0.5) 0.7 (0.1,6.9) We are indebted to the study participants, data collectors and supervisors for
a
Exclusive breastfeeding their commitment in the study.
b
Crude Odds Ratio
c
Adjusted Odds Ratio Funding
**significant at a p-value of < 0.05 No funding was obtained for this study.

Availability of data and materials

they commonly perceived that their infants are not Data will be available upon request from the primary author.
getting enough milk, and therefore they may fail to
Authors’ contributions
provide breast milk. HG Conceived the study, coordinated data collection, performed the
This study also affirmed that continuous exclusive statistical analysis, and drafted the manuscript. MK participated in the design
breastfeeding rate was higher among mothers who re- of the study and tool development, performed statistical analysis, and
drafted the manuscript. AT participated in the design of the study and tool
ceived breastfeeding support. This finding was compar- development, performed statistical analysis, and drafted and reviewed the
able with study conducted in Malawi [25] and research manuscript. All authors read and approved the final manuscript.
done in southern Ethiopia [24]. A similar finding was
Competing interests
also reported from Swaziland [36], in which social sup- Authors declare that they have no any conflict of interest.
port increased the ease of breastfeeding. In fact, socio-
cultural and economical support has a great role in Consent for publication
obtaining the full benefits of breastfeeding, and the pro- Not applicable.

found effect in maintaining optimal breastfeeding was Ethics approval and consent to participate
noted in case of family support [35, 37]. Ethical clearance was obtained from the Ethical Review Board of the University
Of the commonly documented determinants of EBF, of Gondar (Ref. No/IPH/2906/2016). A letter of permission was obtained from the
Chief Executive Officers of the hospitals under study prior to the data collection.
maternal health care utilizations, such as antenatal care After the objective of the study was explained, verbal and written consent was
and institutional delivery were consistently reported by secured from the mothers. The right of participants to withdraw from the study at
various studies [18, 20, 22, 25, 40]. But, these variables any time without any precondition was disclosed unequivocally. Moreover, the
confidentiality of information obtained was guaranteed by all data collectors and
did not show significant association with continuous investigators by using code numbers rather than personal identifiers and by
EBF in the current study. The discrepancy might be keeping the data locked.
Genetu et al. International Breastfeeding Journal (2017) 12:21 Page 8 of 8

Publisher’s Note 20. Demelew MZ, Abdeta G. Assessment of exclusive breastfeeding practice
Springer Nature remains neutral with regard to jurisdictional claims in among HIV positive women in Addis Ababa. Afr J Midwifery Womens
published maps and institutional affiliations. Health. 2014;8(1):14–20.
21. Bekere A, Garoma W, Beyene F. Exclusive breastfeeding practices of HIV
Author details positive mothers and its determinants in selected health institution of West
1
Gondar University Hospital, Gondar, Ethiopia. 2Department of Epidemiology Oromia, Ethiopia. J Nutr Food Sci. 2014;4:6.
and Biostatistics, College of Medicine and Health Sciences, Institute of Public 22. Muluye D, Woldeyohannes D, Gizachew M, Tiruneh M. Infant feeding practice
Health, University of Gondar, Gondar, Ethiopia. 3Department of Human and associated factors of HIV positive mothers attending prevention of mother
Nutrition, College of Medicine and Health Sciences, Institute of Public Health, to child transmission and antiretroviral therapy clinics in Gondar Town health
University of Gondar, Gondar, Ethiopia. institutions, Northwest Ethiopia. BMC Public Health. 2012;12:240.
23. Matovu S, Kirunda B, Rugamba-Kabagambe G, Tumwesigye N, Nuwaha F.
Received: 16 June 2016 Accepted: 18 April 2017 Factors influencing adherence to exclusive breastfeeding among HIV positive
mothers in Kabarole District, Uganda. East Afr Med J. 2008;85(4):162–70.
24. Haile D, Belachew T, Birhanu G, Setegn T, Biadgilign S. Predictors of breastfeeding
cessation among HIV infected mothers in southern Ethiopia: a survival analysis.
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