About 29 % of children received prelacteal feeds within the first 3 days of birth which is lower than other previous studies, 41 % in Southern [20], 45.4 % [24] in Eastern and 80 % in North [14] Ethiopia. The possible reason for the inconsistency with southern and northern studies might be due to study participants were only from rural community whereby they might have less access to media and health care, whereas the current study was based on national data. On the other hand, study conducted in eastern Ethiopia was based on sample of mothers-child pairs visiting the public health institutions in specific district of the country and overlooked those children at home. Otherwise, prelacteal feeding is often described as traditional practice related with birth in Ethiopia [21]. The current finding is also lower than reports from other developing countries (35–81.8 %) [6–13]. The main reason could be the difference in context, and health policy our country currently implementing which is mainly focused on prevention with community involvement about different health issues (with especial attention to mothers and infants) through implementing health extension program that works with health development army comprised of the community. Despite the implementation of such program, the current finding suggested the prevalence of prelacteal feeding is still high that could be an implication for low OBF practice in the country, indicating the need to strengthen the program in way to reduce prelacteal feeding practice.
Breastfeeding interventions involving respected members (like religious and community leaders) at each level of breastfeeding promotion programmes are suggested to promote OBF [28, 29]. Likewise, the current study also showed the importance of involving community and religious leaders in breastfeeding promotion programs, in which there was statistically significant difference in the prevalence of prelacteal feeding practice among ethnic and religious groups. This is consistent with other studies conducted in Nepal, Laos and China [8, 10, 30], that reported ethnicity of woman was significantly associated with mothers’ decision to give prelacteal feeds. Similarly, this is consistent with other studies findings in which some religious cultures promote the practice of prelacteal feeding [31–33]. However it is not a religious practice, it is a cultural practice that originated from religious setting [33]. Thus, ethnicity and religions could have their own found on initiation of traditions like practice of prelacteal feeding. Nevertheless, this finding indicates that there is a need to focus on community and religious leaders as information on infant feeding provided by both ethnic and religious group leaders could be more likely to be accepted and changed to practice especially in case of Ethiopia.
The current study also revealed that, the higher household economic status was negatively associated with introduction of prelacteal feeding. This finding is in-consistent with studies conducted in Vietnam and Nepal [22, 34] that reported high socioeconomic status promotes introduction of prelacteal feeding. This could be because of the difference in culture on preferring type of prelacteal feeds. In these studies prelacteals used were costly to be used by lower socioeconomic status; hence only those mothers from high socioeconomic status bought and fed their newborn. However, butter and plain water were more commonly provided prelacteals that can be easily accessible to majority of Ethiopians. Besides, it could be also explained by the fact that higher proportions of women from higher socioeconomic status (SES) are educated and possibly discouraged prelacteal feeding than those from lower SES according to EDHS 2011 report [5].
Giving birth on the hand of health personnel had a negative effect on introduction of prelacteal feeding in the current study, which is consistent with other studies in India and Bolivia [12, 35]. This could be because mothers who delivered on hand of health personnel are more likely to be encouraged and counseled for healthy infant feeding practices. In line with other studies in Egypt, Kuwait and Nigeria [7, 36, 37], the current study also reported cesarean mode of delivery was associated with higher odds of prelacteal feeding. Initiation of breastfeeding within 1 h of birth was associated with lower odds of the introduction of prelacteal feeding. This is consistent with reports of several studies [7, 17, 37]. This might be because those mothers who are late on initiation have miss-perception on colostrum feeding and/or have cultural practice to feed other than breast milk, thus more likely to feed prelacteals. The current study also found that lower size of child was important factor that encourages mothers’ decision to give prelacteal feed, which is consistent with findings of study conducted in Egypt [7]. This could be due to the miss-perception by mothers in which the lower size births could benefit from feeding their newborn with feeds other than breast milk and/or miss-perception that only breast milk can’t meet the nutritional need of the newborn.
The characteristics of community where a woman is living have a significant positive or negative effect on her decision to feed her newborn. The current study found that living in different contextual regions showed significant difference on women decision to introduce prelacteal feed, that is consistent with finding of study in Nepal [34]. This could be explained by difference in living situations, and access to health facilities, media and information across regions. Therefore, this finding indicates that there is a need to focus on reducing differences in access to health care and information while implementing breastfeeding promotion programs.
Antenatal care visit is a best opportunity to promote skilled attendance at birth, and to counsel and educate mothers on essential healthy behaviors like newborn feeding; hence mothers who have visit were more educated or aware of these healthy behaviors and discourage prelacteal feeding [38]. Likewise, as there is higher number of women who visited ANC in a community, the more likely to develop a norm that discourages prelacteal feeding. This effect was indicated by the current study in which living in the community where there is high ANC use discouraged the mother to feed prelacteal to their newborn. Generally, reaching women with health education (counseling) and strengthening the community involvement that currently the government of Ethiopia implementing to increase maternal and child health service coverage can increase the OBF practice and discourage traditional feeding practices like prelacteal feeding.
The current study found that; even if most variation on introduction of prelacteal feeding was explained by individual-level factors, substantial proportion of variation in prelacteal feeding practice was also explained by unmeasured community-level factors. The random effects of the community-level were significant in explaining the prelacteal feeding practice even though it reduced in full model, from 39 % in null model to 26.7 % in full model. This indicates the community-level effect was high and mothers’ decision on giving prelacteal feeding was explained by both individual and community-level factors. However, since the unexplained community variance was still significant after controlling for community variables in the combined model further study should be designed to explore additional community-level factors, and factors evidenced to have effect but not included in this study like knowledge of mother towards breast feeding.
Strengths and limitations of the study
The current study was conducted by using a multilevel analytical approach that can able to identify the multilevel determinants of introduction of prelacteal feeding and provides important insight to design most appropriate multilevel interventions. Moreover, the results are representative of the entire Ethiopian population because appropriate estimation adjustments such as weighting, accounting for sample design were applied for analysis. Thus, it is the first nationally representative study to report on multilevel factors associated with the introduction of prelacteal feeds. It is also the first to examine the influence of ethnicity and religion on mothers’ decision to give prelacteals to their newborn in Ethiopia.
Despite its strength, the findings of the current study should be interpreted in light of its limitations. Analyses are based on multilevel logit models with random (varying) intercept and fixed coefficients only. Hence, the findings cannot provide evidence of the effects of individual factors variance across communities. The data was collected based on recall that may increase the risk of recall-bias. Finally, EDHS did not collect some information such as maternal beliefs, miss-conceptions and knowledge towards breastfeeding that were evidenced to influence introduction of prelacteal feeding [22, 39], thus their effect was not controlled and seen in this study that might lead to residual confounding.