Study setting and participants
North Wollo zone is one of the ten zones (the smallest administrative units next to region in Ethiopia) of the Amhara Regional State. It is bordered on the south by South Wollo Zone, on the west by South Gondar, on the north by Wag Hemra, on the northeast by Tigray Region, and on the east by Afar Region. The towns in North Wollo zone include Lalibela, Woldia and Kobo. Based on the 2007 Census conducted by the central statistical agency of Ethiopia, this Zone has a total population of 1,500,303, of whom 752,895 are men and 747,408 women. The largest ethnic group reported in North Wollo zone is the Amhara (99.38%) and Amharic is spoken as a first language by 99.28%.
This study was conducted in Woldia, Kobo and Lalibela towns of North Wollo zone in March 2015. Woldia is the capital of North Wollo zone. It is located 521 km north of Addis Ababa and about 360 km south of the capital of Amhara regional state, Bahirdar. This town has eight kebeles (the smallest administrative units next to district in Ethiopia). Based on the 2007 national census conducted by the central statistical agency of Ethiopia, this town has a total population of 46,139, of whom 23,000 are men and 23,139 women. Kobo town is located in the northeast corner of North Wollo zone. Kobo and Lalibela town administrations consist of five and two kebeles, respectively. The majority of the inhabitants in the three towns (Woldia, Kobo and Lalibela) were Amhara and followers of Ethiopian orthodox Christians.
A quantitative community based cross sectional study was employed to survey 810 mothers of children aged less than 24 months. The sample size was determined using a single population proportion formula:
$$ \mathrm{n}=\mathrm{D}\left[\frac{{\left(\mathrm{Z}\frac{\upalpha}{2}\right)}^2\mathrm{p}\left(1-\mathrm{p}\right)}{{\mathrm{d}}^2}\right] $$
Where n = required sample size, Z = critical value for normal distribution at 95% confidence level (1.96), P = prevalence of colostrum avoidance (39.8%) [20], d = 0.05 (5% margin of error), D = 2 (design effect), and an estimated non-response rate of 10%.
Sampling procedure and technique
First the three towns were selected purposely since these towns are the first three top ranked town administrations (Woldia, Kobo and Lalibela) in North Wollo Zone. Out of the fifteen kebeles in the three towns, eight kebeles were randomly selected. Presurvey was done before the actual period of data collection to know which households have the targeted mother-child pairs. As a result, there were 6013 households having the targeted mother-child pairs in the selected eight Kebeles. Then, the sample size was proportionally allocated to each selected kebeles. At the time of survey, from each household unit one eligible mother who had a biological child aged less than 24 months was selected. If there were more than one mother with children aged less than 24 months in one household unit, one mother with the youngest child was selected. From mothers who had two children aged less than 24 months, the youngest child was selected. If mothers had twin children aged less than 24 months, one child was selected by lottery. Non-biological and mothers who are unable to communicate were excluded from the study.
Study variables
In this study the outcome variable was colostrum avoidance among mothers of children aged less than 24 months. Colostrum avoidance is failure to feed infants with the first, thick and yellowish milk that is produced in the first 3 days after birth [1]. Discarding colostrum was coded as “1” while colostrum feeding was coded as “0” for regression analysis. The independent variables were maternal characteristics (age, parity, educational status, religion, ethnicity, marital status, occupation), maternal health service and obstetric variables (antenatal care visit, place of delivery, mode of delivery, postnatal care visit), child’s sex, breastfeeding initiation, breastfeeding counseling during antenatal care visits and prelacteal feeding. Prelacteal feeding was understood as providing foods and/or drinks other than human milk for the infant before breastfeeding initiation [1].
Data collection procedure and quality control
Data were collected using a pre-tested, structured and interviewer administered questionnaire. The questionnaire was prepared first in English and translated to Amharic (local language), then back to English to check for consistency. The Amharic version of the questionnaire was used to collect the data. The data were collected by six diploma midwives. The data collectors and the supervisors (three BSc nurses) were trained for 2 days by the investigators on the study instrument, consent form, how to interview and data collection procedures.
Then questionnaire was pretested on mother-child pairs in two kebeles which were not included in the research. The pretest was done to ensure clarity, wordings, logical sequence and skip patterns of the questions. Then the pretest amendments on the questionnaire were made accordingly. The supervisors had checked the day to day activity of data collectors regarding the completion of questionnaires, clarity of responses and proper coding of the responses.
Data processing and analysis
The data were checked for completeness and inconsistencies. It was also cleaned, coded and entered into EpiData version 3.02, then exported to the SPSS 20.0 statistical package for analysis. Descriptive statistics were used to show the prevalence of colostrum avoidance practices and socio-demographic characteristics.
Binary logistic regression analysis was performed. The crude odds ratio (COR) with 95% confidence interval was estimated to assess the association between each independent variables and the outcome variable, and to select candidate variables for the multivariable logistic regression analysis. Variables found statistically significant at p-value < 0.25 [21] during binary logistic regression analysis were included in the multivariable logistic regression model.
The Hosmer-Lemeshow goodness-of-fit with enter procedure was used to test for model fitness. Adjusted odds ratio (AOR) with 95% confidence interval was estimated to assess the strength of the association, and a p-value < 0.05 was used to declare the statistical significance in the multivariable analysis. Variables with p-value < 0.05 in the multivariable logistic regression analysis were considered as significant and independent predictors of colostrum avoidance.
Ethical consideration
The study was approved by institutional research ethics review committee (IRERC) of Woldia University. An official letter was written from research and development office of Woldia University to Woldia, Kobo and Lalibela town’s administration office. Then permission and support letter was written to each selected kebeles. Informed verbal consent was taken from the participants before the interview. The participants were also assured about the confidentiality of the information they provided.
