CHAPTER ONE

Introduction1.1 Background Information After birth the health of the baby depends upon thenurturing practice adopted by the family. The idealfood for the young infant is human milk which has thespecific characteristics that match the growinginfants’ nutritional requirements. Breastfeeding is asocially constructed and controlled practice. It isoften presented as a natural practice. As a global goalfor optimal maternal and child health and nutrition,all women should be enabled to practice exclusivebreastfeeding, and all infants should be fedexclusively on breast milk, from birth to 6 month ofage. (22)

Breastfeeding is nearly universal in Nepal and themedian duration of breast-feeding is long (33 months).But on the contrary to the recommendations of WHO only2/3rdn of children less than 6 months of age areexclusively breast fed. (9)

Numerous barriers to breast-feeding like lack ofaccurate information and lack of appropriate knowledgeamong the population in general have been identified.According to a published survey a major barrier to

1

successful in-hospital breast-feeding is inconsistencyin information and nursery practices related tobreastfeeding management. This study was carried outbased on the fact that knowledge of mothers and theirappropriate practice regarding breastfeeding islimited, then focusing on mother’ s point of viewtowards breast-feeding.(10) Breastfeeding in Ethiopia,the historical development of Primary Health Care (PHC)and its application to the Ethiopian situation. Thiswill help become aware of place as a health workerwithin the Ethiopian Health Service which is currentlygoing through rapid change and development. (19)

It will also learn about the overall concepts ofPrimary Health Care (PHC) and the implementation of theEthiopian Health Extension Programmer, and find outabout some of the successes that the country hasachieved in improving the health service and the healthof its communities. Ethiopia is committed to workingtowards the Millennium Development Goals (MDG) and thisstudy will include some information about the way thatthe MDG health-related goals are being focused on.(4)

Breastfeeding is an important public health strategyfor improving infant and child morbidity and mortality,improving maternal morbidity, and helping to control

2

health care costs. Breastfeeding is associated with areduced risk of otitis media, gastroenteritis,respiratory illness, sudden infant death syndrome,necrotizing enter colitis, obesity, and hypertension(1). The World Health Organization (WHO) and UnitedNations Children’s Fund (UNICEF) recommend that everyinfant should be exclusively breastfed for the firstsix months of life, with breastfeeding continuing forup to two years of age or longer (2-4). Exclusivebreastfeeding is defined as feeding the infant onlybreast milk, with no supplemental liquids or solidsexcept for liquid medicine and vitamin/mineralsupplements.(5)

Variables that may influence breastfeeding includerace, maternal age, maternal employment, level ofeducation of parents, socio-economic status,insufficient milk supply, infant health problems,maternal obesity, smoking, parity, method of delivery,maternal interest and other related factors. A numberof studies have addressed breastfeeding in differentparts of World in respect of relevant statistics,factors influencing breastfeeding and attitudes towardsbreastfeeding. (7)

They exert a tremendous socializing influence on up-coming generations [13]. Dissemination of breastfeedingknowledge to this population should have a striking

3

impact on child health in the country in the short-to-medium term, as well as in the more distant future,

since mothers are the best suited to pass on correctattitudes to the mothers of tomorrow [6]. The presentstudy was undertaken, therefore, to assessment ofknowledge, attitude and practice (KAP) of mothers toward breastfeeding at Soddo Zurya district Gido kebele,and to compare them against international standards,identify factors which mitigate breastfeeding KAP andmake suggestions for minimizing obstacles tosatisfactory breastfeeding.

1.2 Statement of the ProblemAlthough the World Health Organization (WHO) hasdefined the indicators for assessing of KAP of mothertowards breastfeeding practices in 1991 (24), variousdefinitions of breastfeeding were used in differentpapers and countries. A recent study indicated thatonly half of the studies assessing breastfeedingconducted in Australia used a definition consistentwith that of the WHO (25).

In Ethiopia, a review indicated that less than 8% ofthe studies used the WHO definition when measuringbreastfeeding and more than half of the studies did not

4

define breastfeeding practices (15). It is important touse a valid and consistent definition to measurebreastfeeding practices when monitoring and comparingbreastfeeding rates and trends among different studiesand countries. In this study, we strictly followed theWHO definition, updated in 2008, to measurebreastfeeding practices (20).

The trend in breastfeeding has changed considerably inthe past 40 years. Before the 1960s almost all mothersbreastfed their infants in both urban and rural areasof Ethiopia (6). However, in the 1990s, the use offormula became widespread, and breastfeeding started todecline (7). The breastfeeding rate (referring to allmothers who had ever breastfed) declined from 80% in1970 and 62.7% in 1985 to 53.6% in 1995 (7).

A national survey of 20 provinces in 1994 reported thatbreastfeeding rates at 4 and 6 months were 62.5% and54.3% in urban areas, and 90.0% and 80.4% in ruralareas, respectively (8). The duration of breastfeedingalso declined from 36 months in 1962 to 24 months in1992 (9). In 1989, a WHO/UNICEF joint statement “Tensteps to successful breastfeeding” was announced (5).In early 1998s, the Ethiopian government set a nationaltarget to enhance exclusive breastfeeding rate at 4months and to generally promote breastfeeding to thepublic (13).

5

The breastfeeding rate began to increase in mid 2000s.But it was reported that in big cities includingHawassa, Bahir-Dari, Mekele,Adama and other big cities,the artificial feeding rate has increased and thebreastfeeding rate has declined in recent years (10).

In rural areas, more mothers chose breastfeeding foreconomic reasons (2). In rural area of Ethiopia, fullbreastfeeding rate at 24 months and breastfeeding ratewere higher and the duration of breastfeeding waslonger than in urban area.

Today, MoHs adopted the world deceleration forconference held in Amsterdam in October 1992. Thecontrol of breastfeeding has been recognized as aglobal priority. It was emphasized that local problemand priorities should be identified and appropriatedesigned according to local situation. (8)

Research project for breastfeeding must involvecommunity to elicit strategies to be successful andprograms to be sustainable. Therefore, Knowledge,attitude and practices the population concerned must betaken in to account in the design of improving againstbreastfeeding. (11)

The traditional post-natal care for 40-days afterdelivery is routinely implemented in all but the purepastoralists' households. This encourages mothers toeat nourishing food and to focus on breastfeeding in

6

the initial weeks after delivery. However mother oftencite lack of resources to purchase the necessary foods.

Breastfeeding is mainly influenced by socialenvironment, especially by maternal grandmothers andother elderly women in the community. Althoughbreastfeeding is acceptable to all, infants are firstintroduced to sugary water after birth around the 3rdor 4th day after delivery. This is to avoid thecolostrum (first milk) that is generally discarded bythe mother as considered heavy, thick, coarse, dirty,toxic, and harmful to children's health. Exclusivebreastfeeding is not practiced, as breast milk alone isconsidered inadequate and water essential to cool thebaby and quench their thirst. On a positive note, theagreed and acceptable duration of breastfeeding is 24months.

However, this is rarely implemented for two mainreasons - very close birth spacing, since once a womendiscovers she is pregnant she stops breastfeeding, andan increasing trend of mothers working outside thehome, resulting in early separation from the infant.The study also found that there is a lack of orinappropriate knowledge of proper complementary feedingpractices across all livelihood groups. Earlyintroduction of complementary foods (from birth tothree months) is common, mainly as cows/goat's milk(involving no special preparation or storage), tea and

7

porridge. The poorer households report limited accessto milk, which they replace with tea/porridge after 3months. Lack of dietary variety is typical among theriverine and, to a lesser extent, the agro pastoralcommunity, where children are mainly fed a cereal-baseddiet. Tea is often given to children as a snack beforemeals, which reduces stomach capacity and appetite andinterferes with nutrient absorption. During illness,special diets for quick recovery include avoidinganimal protein-based foods, which are believed toaggravate illnesses. (13 &17) Knowledge on the use of Oral Rehydration Salts (ORS)for diarrhea was good, with local adaptations usinglemon or water melon juice. Access to safe water is ofmajor concern, with most households relying onunprotected sources. Water treatment at household levelrarely happens. Unsafe water and childhood diarrhea arethe strongest associated factor with childhoodmalnutrition in Ethiopia. (25)

Sanitation/water related diseases including diarrhea,acute respiratory infection (ARI), intestinal parasiticinfestations and skin/eye infections are the mainreported illnesses. Access to formal health services is limited orunavailable, especially among the rural population.Responses to illnesses tend to follow a generalizedpattern of: Prayer - Traditional home health practice -Traditional healer -Buy medicine - Get to pray -Healthfacility. (21)

8

This clearly shows the lack of knowledge of, orconfidence in, more modern health care practices. Manyof the traditional practices are harmful, such asburning of the feet for nutritional edema, and oftenresult in the child becoming sicker before they arefinally taken for conventional treatment. In conclusion, the study revealed glaring evidencesthat mother breastfeeding and care practices are belowthe acceptable standards. Much of this can beattributed to poor knowledge, with poor practicesexacerbated by the collapse of the basic infrastructureresulting from the war in the early 90's. The studyrecommends participatory dissemination of the studyfindings, training, advocacy and active involvement ofkey community change agents (religious/traditional andprofessionals) and caregivers in generating solutionsfor the challenges highlighted. Parallel campaigns andinterventions are needed that focus on basic healthcare, hygiene, sanitation, safe water and child feedingpractices. The importance of mother breastfeeding inimparting positive messages relating to child care andhygiene is very evident, highlighting a clear entrypoint for community sensitization and future behaviorchange. (6)

9

1.3 Significance of the Study

The study can extract significance KAP about theways how traditionally societies among or motherstoward breastfeeding and there by the positive ornegative impacts that the traditional mannerscontribute to sustainable development and to thinkover what types intervention and new technologyneeded to be designed.

This study helps to have information on anassessment of KAP of mothers towards breastfeedingsystem of Gido Kebele.

The information may be used by any group or bodywho wants to carry further researchers about KAP ofmothers towards breastfeeding system.

It may also be help to identify critical point formothers toward breastfeeding in the Gido Kebele.

The finding may be also used by the responsiblesectors and stakeholders for the improvement of thepublic health issues, and help to them to know

10

about mothers toward breastfeeding system in GidoKebele.

Moreover, the finding may be used by concernedgovernmental bodies to plan, improve, maximize anddesign project related problems.

CHAPTER TWOLiterature Review

2.1 Definition of breastfeedingAlthough the World Health Organization (WHO) hasdefined the indicators for assessing breastfeedingpractices in 1991 (24), various definitions ofbreastfeeding were used in different papers andcountries. A recent study indicated that only half of

11

the studies assessing breastfeeding conducted inAustralia used a definition consistent with that of theWHO (25). In China, a review indicated that less than8% (9) of the studies used the WHO definition whenmeasuring breastfeeding and more than half of thestudies did not define breastfeeding practices (15). Itis important to use a valid and consistent definitionto measure breastfeeding practices when monitoring andcomparing breastfeeding rates and trends amongdifferent studies and countries. In this study, westrictly followed the WHO definition, updated in 2008,to measure breastfeeding practices (6).

2.2 Benefits of breastfeedingThere is consistent evidence of short-term benefits andpotential long-term benefits in breastfed infants. Inaddition, benefits of breastfeeding to maternal health,as well as advantages for health care systems andsociety, have been described.

The components of breast milk exert dual roles; one isto provide nutrition and another is to encourageimmunity and development (7-9). Breast milk changes itscomposition from colostrum to mature milk to meet thedifferent stages of nutrition needs from newborns toolder infants (7).

12

It provides the required nutrients in easilydigestible and bioavailable forms (3). Breast milk alsocontains a wide variety of living components includingantibodies, enzymes and hormones (9). The healthbenefits by breast milk cannot be replaced by formulamilk.

Bioactive factors such as human secretoryimmunoglobulin A (sIgA), lactoferrin, lysozyme,oligosaccharides, growth factors and cellularcomponents may benefit infant’s host defense system(13). There is convincing evidence that breastfeedingreduces infant mortality and decreases the risk ofacute illnesses such as gastrointestinal infections,lower respiratory tract diseases and acute otitis media(12).

In developing countries, breastfeeding is a life-or-death issue. A meta-analysis showed significantprotective effects of breastfeeding (13). This paperfound that infants who were not breastfed had a risk ofdying from infectious diseases in the first month oflife six folds greater than those who were breastfed(33). Significant reduction in the risks ofgastrointestinal infections, lower respiratory tractdiseases and acute otitis media were also observed indeveloped countries that can be directly attributed tobreastfeeding. In addition, a systematic reviewconcluded that breastfeeding is associated with lower

13

rates of childhood obesity, certain allergicconditions, type 2diabetes and leukemia (12).

However, most of the studies involved in the reviewwere observational studies, therefore causalrelationships between breastfeeding and health outcomescould not be inferred.

Conflicting data regarding the association betweenbreastfeeding and obesity were observed. WHO publisheda report (14) concluding that some evidence suggestedthat breastfeeding may have a small protective effectagainst obesity.

Cope and Allison (15) critically reviewed the WHOreport and concluded that although the benefits ofbreastfeeding most likely outweighed any harms, anystatement that a strong, clear or consistent body ofevidence showed that breastfeeding causally reduced therisk of becoming overweight or obese was unwarranted.

The small differences in the WHO report (14) may havebeen influenced by publication bias and confounders. Arecent meta-analysis indicated that breastfeedingreduced the odds ratio for obesity at school age byabout 20%, after adjusting for confounding variables or

14

interacting factors such as infant birth weight,parental overweight, parental smoking, dietary factors,physical activity and maternal socioeconomic status(16).

In view of the controversial data regarding protectiveeffects of breastfeeding against obesity, more studiesare needed in order to advocate breastfeeding as amethod for reducing obesity. There is stillconsiderable debate concerning the protective effect ofbreastfeeding against allergic diseases. Because of theimmunologic complexity of breastfeeding and geneticdifferences between patients,(7) found that it wasdifficult to conclude whether breastfeeding wasprotective against the development of allergies or wasin fact sensitizing; however, foregoing thenutritional, psychological and other immunologicalbenefits of breastfeeding would be unwise.Breastfeeding should be encouraged for infants both athigh and low risks.

There are some other potential long-term benefits ofbreastfeeding for infants, such as higher cognitiveoutcome in full-term infants, less cardiovascularmortality in adults and lower adult blood pressure. Butthese associations cannot be adequately addressedwithout adjusting for residual confounding variables(12).

15

Breastfeeding is also beneficial for mothers, includingdecreased risks of type diabetes, breast cancer,ovarian cancer and maternal postpartum depression.(8)

A study of two large cohorts including 150,000 porousfemale nurses in the United States (11) found that,without a history of gestational diabetes, eachadditional year of breastfeeding was associated with a4% reduction in the risk of developing type 2diabetesin the first cohort and a 12% reduction in the risk inthe second cohort.

There is good evidence from the latest meta-analyses tosupport that breastfeeding is associated with areduction in the risk of breast cancer. A collaborativereanalysis study including more than 50,000 women withbreast cancer and more than 90,000 controls examinedindividual data from 47 studies and found that therelative risk of breast cancer decreased by 4.3% forevery 12 months of breastfeeding, in addition to adecrease of 7.0% for each birth (3).

The Agency for Healthcare Research and Quality (2)reviewed 9 case-control studies and concluded thatthere was an association between breastfeeding and a21% (95% CI: 9%, 32%) reduction in the risk of ovarian

16

cancer, compared to never breastfeeding. Three studiesfound an association between breastfeeding and anincreased risk of postnatal depression (8-10). However,none of these studies screened for baseline depressionand the definitions of breastfeeding were unclear. Moreinvestigation is needed to determine the nature of thisassociation.

In addition to the specific health advantages forinfants and mothers, breastfeeding also benefitssociety by reducing health care costs, parentalemployee absenteeism and associated loss of familyincome.

As breastfeeding benefits the health of infants andmothers, it decreases the cost to families, employers,society and health care systems by reducing the costsof buying infant formula, parental employee absenteeismand the expenses of medical care (duration ofhospitalization, health service use).

A study in the United States estimated that if 50% ofinfants were exclusively breastfed for the first threemonths of life, approximately $4 million per monthwould be saved (4).

2.3 Breastfeeding rate andpractices

17

Breastfeeding rates vary by region, country andculture. Worldwide, it is estimated that only aboutone-third of infants were exclusively breastfed for thefirst six months of life in 2009 (4). The exclusivebreastfeeding rate at six months increased from 33% in1996 to 37% in 2006, according to the data from 64developing countries (4). The exclusive breastfeedingrate significantly increased in sub-Saharan Africa from22% to 30%, Europe from 10% to 19% and Latin Americaand the Caribbean from 30% to 45% between 1996 and 2006(5). There was an increasing trend in breastfeedingrates in many regions. However, breastfeeding rateswere still far below the WHO-recommended levels.

18

CHAPTER THREE

Objective3.1 General objectiveTo assess the KAP of mothers toward the common methodof breastfeeding and related determinants among nursingmothers in Soddo Zuria Woreda Gido Kebele households.

3.2 Specific objectives1. To assess socioeconomic factors that affects the KAPof households.

2. To assess the knowledge of households towards commonmethod of breastfeeding.

3. To assess attitude of households mothers towardsbreastfeeding.

4. To examine other factors influencing breastfeedingpractices.

19

CHAPTER FOUR4. Materials and Methods

4.1 Study areaGido Kebele is found in Wolaita Zone Soddo Zuria Woredain the SNNPRS. Soddo is 330km south of Addis Ababa atthe edge of the Great Rift Valley with beautifulweather at 7,400 feet elevation. Misty green mountainshedge the city, and the climate is moderate andpleasant. October through April is the driest andhottest season, with temperatures ranging from 52 to 80degree Fahrenheit. May to September is more moderate,with temperatures reaching 70 degrees. Two rainyseasons occur: February to March and May to September.The total population of the Zone around 3million andthe total population of the k/ketema are estimated tobe 5,596 with total 2,286 households will be conduct.It has five kindergartens, five primer schools, four

20

high schools, tow preparatory school, one privet andone governmental TVETC College, one privet hospital,tow health center, and four privet health clinics(CSA). It is important to obtain updated data onbreastfeeding practice and investigate the factorsinfluencing breastfeeding duration in order to achieveWHO infant feeding recommendation and national target.The last report on breastfeeding practice in Gidokebele was in 2005. (25)

4.2 Study design and periodA cross-sectional study will be conduct from January 1st

to April 30th, 2014.

4.3 Population4.3.1 Source Population The reference population of the study willbe the Gido Kebele resident.

4.3.2 Study Population and Subject

21

All households from the source populationselect a residential area, from Gido kebele, take bychance will be include residents. The study subjectwill be the residential households select based on theworeda socio-economic profile of 2002-2005 (E.C.),which population will be living in, are include in thestudy as household.

Inclusion and Exclusion Criteria

- In order to investigate the breastfeeding rate at,the present study only includes mothers with infantsover 6 months postpartum.

-We only include mothers with infants less than 24months when maternal recall breastfeeding practices arelikely to be reliable and valid.

- We include age b/n 20-49 years and who are able torespond.

-Exclude those who don’t fulfill the inclusioncriteria.

4.4 Sampling Technique andSample Size 4.4.1 Sampling TechniqueA simple random sampling technique is use indetermining the sample size n; systematic random

22

sampling in determining the sample fraction, K and thestudy unites or households. From the list of the Kebeleresident registration book.

4.4.2 Sample Size DeterminationThe total sample size (n) of the study include 10%non-respondants will be calculate using populationproportion formula,

n = z 2 p(1-p)

w2

n = (1.96)2(0.5)(0.5)=384, Total sample size are

(0.05) 2

384+38.4 = 422HHs

Where: - n = 384, which is calculate sample size of theKebele.

Z = 1.96, which is reliabilitycoefficient for 96% level of confidence.

P = 0.5, which is estimate 50% how bigthe population proportion.

W = +- 0.05, which is margin of error orthe degree of precision.

23

To determine the value of k, which is the samplingfraction; k = N/n, where;

N = 5596, which is the HH population of theGido Kebele.

n = 384, which is the sample size of the HHpopulation, and since the k value is 15, starting fromrandomly select HH, every 15th household is the studyunit of the study population.

4.5 Data CollectionData will be collect based on an assessment of motherstoward breastfeeding common method and managementsystem using structure questionnaires and focus groupdiscussion (FGD).

The questionnaires will be distribute to datacollectors, prior to data collection instrument will bepre-test, data collectors will be train. All necessarytechniques and procedures of data collection is carryout.

The questionnaires contain both close ended and openended items that is fill with free responsible of therespondents. The focus group discussion (FGD) pointswill be focus on the identification of the problem andsolutions.

24

4.6 Data Analyses andInterpretation The data is compiling categorically according to theintentions scheme by using a tally sheet format. Theraw data will be compiling, summarize, andstatistically analyze by using scientific calculatorthe result will be display an appropriate statisticaltestes and parameters, the data present as theproportion and distribution will be interpret based onthe relevant and specific objectives of the study.Finally, relevant and feasible recommendation will bedraw out to the responsible bodies.

4.7 Ethical ConsiderationThe approve by the University, woreda and kebeleadministration will be confirm by recommendationletters they will write to the kebele participation ofall respondents in the questionnaire survey, focusgroup discussions is strictly voluntary, and freedom ofeach individual participating in the study is reserve.

25

CHAPTER FIVEWork Plan and Budget

5.1 Work Plan/Implementation PlanBased on the limited time to complete this study thedetailed work plan is scheduled using Gantt chart asindicated below.

Table 5.1: A Gantt chart showing, Activity andresponsibility Vs time allocated, January, 2014,W/soddo

S.No.

Activities Responsibility

January

February

March

3rd

4rt

1st

2nd

3rd

4th

1st

2nd

3rd

4th

1 Prepareproposal andsubmit toadvisors

ResearchTeam

x x

2 Obtain fund&arrangementswith cityofficial

ResearchTeam

X

3 Preparation Resear x

26

of studytools

chTeam

4 Preparationsfor fieldwork

ResearchTeam

x x

5 Training fordatacollection &assistants

ResearchTeam

x

27

6 Presettinginstruments

ResearchTeam &datacollectors

x x x x

7 Datacollection

x x

8 Focus groupdiscussion (FGD)

x x

9 Datacompilingentrytallying &cleaning

x

10 Dataanalysis,interpretation,recommendation andreport writeup

x x

11 Reportsubmissionandpresentation

x

28

5.2 Personal & Budget The involved personals on the study will be Advisors1 (from WSU Anesthesia department) Research teammembers 3 (from the 3rd years Anesthesia) Data Entryclerk 1 Data collectors 5. For the process of thestudy the following facilities are needed.

Table 5.2: Table showing facilities required for thestudy vs the required quantity, January, 2014, W/soddo.

S.No.

Item/Facilities RequiredQuantity

Remark

1 Scientific calculator 152 Desk top computer 13 Lap top computer 14 Flash Disc 15 LCD-Projector 16 Photocopier 1

29

7 Over-Head projectors(Optional)

1

8 Transportation vehicles 1

Table: 5.3: Table of budget brake down that shows thebudget category Vs cost, January, 2014, Wsoddo.

S.No.

Budgetcategory

Unit cost Multiplyingcost

Totalcost

1 Personnel Daily Wage(incl. perdiem)

No.of staffdays(No. ofstaff x No.of workingday

Principalinvestigator(Subsistenceallowance)

100 1*15 1,500.00

Supervisors’per diem

100 2*15 3,000.00

Datacollectors

60 10*15 9,000.00

Data entryclerk

40 1*20 800

Secretarialwork

40 1*20 800

Sub totalPersonal total

15,100.00

2 Transport Cost/km. Number of km(no.vehicles

30

x no. days xno. km day)

Car 2 birr 4*10*100 4,000.00

Sub totalTransport total

4,000.00

3 Supplies Cost/items NumberQuestionnaireduplication 3birr 1,500 4,500.0

0Clip board 16 13 208.00Clip chartpaper

3 50 150.00

Pen 3 30 90..00

Pencil 1 30 30.00Eraser 1 30 30.00Sharper 2 30 60.00

Marker 12 12 144.00Transparency(pack)

150 1 150.00

Printingpaper (pack)

95 4 380.00

Photocopyingcost

.50 1000 500.00

Printing andBinding

20 10 200.00

Sub total Supplies total 6443.004 Training Cos/items No. of days

Hall rent 200 5days 2,000.0

31

0Tea/coffee 15birr/

participant/day(15*13)=195

5 975

Sub total Training total 2,975.00

5 Total Total (1+2+3+4) 28,518.00

6 Contingency(5%)

5%*total 1,425.90

7 Grand total Total (5)+Contingency (6)

29,943.90

References:1. Chua S, Arulkumaran S, Lim I, Selamat N, Ratnam SS.Influence of breastfeeding and nipple stimulation onpostpartum uterine activity. Br J Obstet Gynaecol. 1994Sep;101(9):804-5.

2. Dewey KG, Heinig MJ, Nommsen LA. Maternal weight-loss patterns duringn prolonged lactation. Am J ClinNutr. 1993 Aug;58(2):162-6.

3. Breast cancer and breastfeeding: collaborativereanalysis of individual data from

47 epidemiological studies in 30 countries, including50302 women with breast cancer and 96973 women withoutthe disease. Lancet. 2002 Jul 20;360(9328):187-95.

32

4. Rosenblatt KA, Thomas DB. Lactation and the risk ofepithelial ovarian cancer. The WHO Collaborative Studyof Neoplasia and Steroid Contraceptives. Int JEpidemiol. 1993 Apr;22(2):192-7.

5. Ball TM, Bennett DM. The Economic Impact ofBreastfeeding. Pediatric Clinics Of North America.2001;48(1):253-62.

6. World Health Organization, UNICEF. Global strategyfor infant and young child

feeding. Geneva: World Health Organization; 2003 [cited2010 02/02]; Available

from:http://www.who.int/child_adolescent_health/documents/9241562218/en/index.html.

7. WHO. Indicators for assessing breastfeedingpractices. Geneva: World Health Organization1991Contract No.: (WHO/CDD/SER/91.14).

8. Binns CW, Fraser ML, Lee AH, Scott J. Definingexclusive breastfeeding in Australia. J Paediatr ChildHealth. 2009 Apr;45(4):174-80.

9. World Health Organization. Indicators for assessinginfant and young child feeding practices. WashintonD.C., USA: World Health Organization2008.

10. National Program of Action for Child Development inEthiopia (1991-2000).

33

Ministry of health of the people's republic of China;1992 [cited /2010 02/02]; Available from:http://www.few.gov.cn/fzgh/et/zget90.htm.

11. National Program of Action for Child Development inEthiopia (2001-2010).81

Ministry of health of the people's Federal democraticrepublic of Ethiopia ; 2001[cited/201002/02] ;Availablefrom:http://www.moh.gov.cn/publicfiles/business/htmlfiles/mohfybjysqwss/s6746/200804/ 18202.htm.

12. Family Health Department. National guideline onthe prevention of Mother -to – child Transmission ofHIV in Ethiopia, Ministry of Health, Addis Ababa,Ethiopia, November 2001.

13. Family Health Department. National Strategy forinfant & young child feeding Federal ministry ofhealth, Ethiopia, April 2004.

14. Nduati R., et al. Effects of breastfeeding andformula feeding on transmission of HIV-1: a randomizedclinical trial. JAMA March 1 2000; 283(9): 1167-1174.

15. UNAIDS. WHO, UNICEF, UNAIDS Statement on currentstatus of WHO/UNAIDS/UNICEF Policy guidelines September1999. Geneva.

34

16. Kesela T. , Kebede D. pattern of feeding of infantsin Addis Ababa, Ethiopia. Ethiop. J. Health Dev. 1996;10(1): 57-65.

17. Rogers, E.M. Communication strategies for FamilyPlanning, Free press, USA. 1973

18. Piotrow etal. Behavior change Model: knowledgeApproval, Intention, practice and Advocacy incommunication framework, JHU. Ccp. 1997

19. CSA. Population and housing census of Ethiopia.Result for SNNP Region, November 1998 Vol. 2:1 – 328.

20. Asefa M., Drewette R., Hewison J. An Ethiopianbirth cohort study: the study design,Ethiop. J. HealthDev. 2002; 16 (special Issue): p. 21 – 36

21. Tekle Silassie B.K. The status of breast feedingamong mothers of children aged less than two years andimplications for the occurrence of acute diarrhea,Jimma, Southwest of Ethiopia. (Unpublished thesissubmitted to Department of Community Health, AAU) 2002.

22. UNICEF. The States of the World’s Children, Focuson Nutrition, Oxford UniversityPress, 1998: p. 28.

23. Semprini AE et al. 1995. The incidence ofcomplications after cesarean section in 156 women. AIDS9: 913-917.

24. Dewey KG, Brown KH. Update on Technical IssuesConcerning Complementary Feeding of Young Children in

35

Developing Countries and Implications for InterventionPrograms. Food and Nutrition Bulletin. Washington, DC,USA: Pan American Health Organization. 2003:24(1):5–28.

25. 2009 annual report of central department ofstatistics and information.http://www.cdsi.gov.sa/socandpub/manpower/cat_view/40---/29--/87--/272----1430-2009 webcite and the ministryof education statistics on general Education SaudiArabia. http://www.moe.gov.sa/Pages/stats31-32.aspxwebcite

Annex IConsent from

Good day, my name is ………………………………………………… I am a studentof in W/soddo University, College of Health sciences. Iand my colleagues are conducting research in yourkebele. The objective of the research is to assess theKAP of mothers toward breastfeeding pattern in the Gido

36

kebele. Therefore, your genuine participation andhonest response will help us to know more about healthconditions of the residents in your kebele.

I am going to ask you same questions. Your answers arecompletely confidential. The information you give mewill never be used in connection with you. You don’thave to answer any question that you do not want toanswer and you my end this interview any time you wentto. We would greatly appreciate your help in respondingto this research. The research will take about 20minutes to ask questions. Would you be willing toparticipate?

Yes ……………….. 1

No ………………... 2 Stop

Annex II HOUSEHOLDS QUESTIONARRIE

37

I – General Description

a) Region ______________ Zone _________

b) K/ketema _____________ Kebele ________

c) Governmental unit _________

d) House hold name __________

e) The household head ……………………………….

f) How many years lived in the village _________

g) Previous residence place A) AmharaB) Afar

C)Oromo D) Somalia

E)Tigiriay F) Other

h) Nations/Ethnics __________ A) Sidamo B) Woliata

C) Gurage D) Oromo F) Tigira G) Amahara H) Other/specific

I) Family size _________

J) Religion ____________ A) Orthodox B) Islam C) Protestant

D)Other/Specify

38

k) Marital statues __________ A) Single B) Separated C) Married

D) Widow E) Divorced

l) Occupation as a mean of level hood ________

m) Wealth rank __________

n) How many live births have you had in your Life…………………?

o) How many children do you have now …………………………………..?

p) What is the main source of drinking water for the members of your households? A) Pipe / tap B) Open well / spring

C) Covered well /spring D) River / pond

E) Rain water F) Other(specify)_________

II Knowledge, Attitude and Practice Mothers toward Breastfeeding

S.No.

Questions Responds Circle

39

1 During your last pregnancy, did you attend antenatal care in any health institution?

Yes No

Don’t know

123

2 If you went for antenatal checkups foryour last pregnancy towhich health institution did you go?

Governmental HospitalGovernmental Health CenterGovernmental ClinicPrivate ClinicOther (specify)_________

12345

3 How many times have you attended the antenatal care in thatspecific health facility?

…………………………. Don’t know 1

4 During antenatal care visits, were you counseled about infantfeeding?

Yes No

12

5 What information (advice) on infant feeding was given to you during the antenatal visits?(Read Choices

if she was not informed-About Breast feeding only-About bottle feeding

12

40

Circle 1 if she was informed2 if she was not informed )

-About supplementaryfeeding-About replacement feeding-Other (specify)__________

6 Where was the place ofyour last child's delivery?

Gvn.t HospitalGvn.t Health CenterGvn.t ClinicPrivate ClinicOwn homeOther (specify)_________

123456

7 Who assisted you during your last child's delivery

Health professionalTrained traditional birth attendantUntrained traditional birth attendantRelative (friends, neighbor)Other (spec)…………

1

2

345

8 What did you give (feed) your baby with in the first three days after delivery, before your white milkbegan flowing

The fluid that came from the breastsButter Water & Sugar Nothing fed Other (spec)

123456

41

regularly? ____________9 Since birth, what did

the child receive? - Water/tea -Water andsugar/salt -Breast milk -Powderedmilk -Cow’s milk -Porridge - Cerealbased fluid -Adult food- Other(spec)……………………….

123456789

10 If the child was ever breast fed, how soon after birth did you first put the child tothebreast?

Hours _________Days _________

11 If the child hasn't fed any- thing except breast milk till now, when do you intend (plan) to start

When the child completes age(in month)_______

42

additional diet?12 Are you still

breastfeeding the child?

Yes No

12

13 How many times did youbreast-feed last nightbetween sunset and sunrise?

Number of night timebreast feedings________

14 When do you usually breast-feed the child?

- When the child wants- When the child cries- On schedule- On convenience-When breast engorged-Other (specify

123456

15 Have you experienced any breast feeding problems while you were breast feeding the last child?

Yes No

12

16 (This question is onlyfor mothers whosechild is not on breast-feeding, never breastfedor ceased breast feeding)

-Not enough milk- Nipple / breast problem-Sourness of the baby's mouth-Mother ill / weak

12

345

43

Why did you stop breast-feeding (neverbreastfed) the last child?

-Child ill / weak-Mother working-Child refused-Weaning age-Become pregnant-Started using contraception-Other (spe)______________

67891011

17 (This question is onlyfor a child older than6 months of age, neverbreast fed at all orceased breast feeding) How many times was the child fed mashed or pureed food or solid or semi-solidfood yesterday during or at night?

Number of time___________ Don't know

12

18 If you offered the child mashed or fluid food, what did you useto give the fluid foods with?

Bottle nippleSpoon (cup)By handOther (specify) ___________

1234

19 Before delivery, what was your intention (plan) to give (feed)

-The fluid that camefrom the breasts-Butter

1

2

44

your baby with in the first three days afterdelivery (before your white milk begins flowing regularly)?

-Water & Sugar-Nothing fed-Other (specify) ____________

34

5

20 Before delivery, what was your intention (plan) to give (feed) your baby from birth upto 12 months after delivery?

-Water/tea-Water and sugar/salt-Breast milk-Powdered milk-Cow’s mi-Porridge-Cereal based fluid-Adult food-Other(specify) ____________

12345678

9

21 For the above foods, the foods you intendedto feed your child, atwhat age was your planto give (start) the intended foods?

Months………………………..

22 Were you able to execute your intentionas you intended (planned) to feed yourchild?

Yes No Don’t know

123

23 Do you have any

45

suggestion to any program (organization)how it could have supported you dealing with the challenges you faced in executingyour infant feeding plan or choice? (Mention only one mainimportant suggestion)

……………………………………………

24 What support from health workers would assist you to better feed your infant? (Mention only one mainimportant suggestion)

…………………………………………

25 If it was your intention to breast feed your baby, how soon after birth was your intention (plan) to put the child to the breast for the first time?

Hours _________Days _________ImmediatelyDon't Know

12

26 Who is the most important when making adecision on how you

-My father-My Husband/ Partner-My mother-My sister

1234

46

should feed your infant?

-My aunt-My self-Health Worker

567

47