Ayana et al.

BMC Res Notes (2017) 10:335

DOI 10.1186/s13104-017-2663-0 BMC Research Notes

RESEARCH ARTICLE Open Access

Complementary feeding practices

among children in Benishangul Gumuz Region,
Ethiopia
Dula Ayana1, Amare Tariku2*, Amsalu Feleke3 and Haile Woldie2

Abstract 
Background:  Appropriate complementary feeding helps to reduces child’s risk of undernutrition, infectious disease
and related mortality. However, complementary feeding practices are sub-optimal in Ethiopia. There is, however, also
limited evidence in the country, particularly of Pawie District. Therefore, this study aimed to assess timely initiation
of complementary feeding and associated factors among mothers who had children aged 6–23 months in Pawie
District, Benishangul Gumuz Regional State.
Methods:  A community based cross-sectional study was conducted in Pawie District from February 01 to March 29,
2015. A multi-stage sampling technique was employed to select 806 mother–child pairs. Multivariable logistic regres-
sion analysis was used to investigate factors associated with timely initiation of complementary feeding. Adjusted
odds ratio (AOR) with corresponding 95% Confidence Interval was calculated to show the strength of association. A p
value of <0.05 was used to declare significance of association.
Results:  The overall prevalence of timely initiation of complementary feeding was 61.8%. One quarter (23.7%) of chil-
dren had good dietary diversity and 32.7% of children aged 12–23 months were fed with appropriate meal frequency.
Mother’s place of residence: urban settlement [AOR = 2.11, 95% CI 1.47, 3.02] and postnatal checkup [AOR = 1.68,
95% CI 1.15, 2.45] were significantly associated with timely initiation of complementary feeding.
Conclusions:  The prevalence of timely initiation of complementary feeding was low in Pawie District. Therefore, fur-
ther strengthening maternal postnatal care utilization is a key to improve timely initiation of complementary feeding.
Moreover, attention needs to be given to the rural mothers.
Keywords:  Complementary feeding practice, Children aged 6–23 months, Ethiopia

Background recommends to initiate nutritionally adequate, safe, and

The first 2  years of life are critical window to promote appropriate complementary food at the age of sixth month
optimal child growth and development of the child [3]. Optimal complementary feeding (CF) helps to reduces
[1]. After the age of sixth month, the energy and nutri- child’s risk of acquisition of different infectious diseases
ent content of breast milk alone is not enough to meet and related mortality [4–6]. Also, it improves the child’s
nutritional demand of the growing infant. Therefore, ini- mental and motor development, and protects against obe-
tiation of complementary feeding, defined as process of sity and other metabolic diseases later in life [7–11].
starting additional foods and liquids along with breast Despite the enormous benefit of appropriate comple-
milk, is essential to ensure optimal catch-up growth [2]. mentary feeding, only 35% of infants worldwide have
To this effect, the World Health Organization (WHO) a timely initiation of CF [12]. In Asia, for instance, the
median age of introducing additional food ranges from
*Correspondence: [email protected]
3.8 months in China to 5.5 months in Japan and Maldives
2
Department of Human Nutrition, Institute of Public Health, College [13]. Similarly, according to the former studies in Africa
of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia less than half of infants start CF at the recommended age
Full list of author information is available at the end of the article

© The Author(s) 2017. 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,
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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.
Ayana et al. BMC Res Notes (2017) 10:335 Page 2 of 8

of 6 months [14–18]. In Ethiopia, the 2011 Demographic Ethiopia. It lies at an area of 5244 square kilometers, and
and Health Survey (EDHS) report indicated that only located 623  km from the capital city of Ethiopia, Addis
49% of infants aged 6–8  months were given any com- Ababa. Administratively the district is structured into 21
plementary food. Surprisingly, only 4% of children aged kebeles (2 urban and 19 rural kebeles, the smallest admin-
6–23  months were found having appropriate infant and istration unit). Based on the 2011 district based census, a
young child feeding (IYCF) practice [19]. total of 76,006 people (37,552 females and 38,454 males)
Inappropriate feeding practice is associated with the live in the Pawe District, of which 6585 were children
adverse and multi-dimensional health and developmental aged 6–23 months. The district has one general hospital,
consequences. It causes more than two-third of under- 4 health centers, and 15 health posts. A mixed farming,
five child mortality [1, 12], in which 41% of these deaths crop and livestock production, is the major the livelihood
occur in Sub-Saharan Africa [20]. In addition, any dam- of the population, and chronic food insecurity is one of
age caused by nutritional deficiencies in the early child- the critical public health problem in the study area and
hood is related to impaired cognitive development, poor the region at large.
educational achievement and low economic productivity
[4, 7, 21]. Inappropriate CF is also associated with child Sample size and sampling procedure
undernutrition [4, 22]. All mothers with children aged 6–23  months who lived
According to studies conducted elsewhere, maternal in Pawe District for at least 6 months were eligible for the
socio-demographic and health care related character- study. A single population proportion formula was used
istics are the significant factors associated with timely to determine sample size by considering the assumptions:
initiation of CF. Married, housewives, unemployed, and expected prevalence of timely initiation of CF in Ethiopia
multi-parous mothers have a higher likelihood of timely as 49% [19], a 95% level of confidence, 5% margin of error
initiation of CF [13–17, 23]. Similarly, antenatal care, (d) and a design effect of 2. Finally, a sample size of 806
postnatal checkup, institutional delivery, and better was obtained after adding a 5% non-response rate.
health care access [24, 25] are positively correlated with A stratified multi-stage sampling technique was
timely initiation of CF. However, mothers with a rural employed to select the study subjects. Following strati-
residence, low child feeding knowledge, perceived inad- fication of kebeles into urban and rural, six kebeles (one
equate breast milk production, maternal and paternal urban and five rural kebeles) were selected using the lot-
illiteracy, and child sex (male) were inversely associated tery method. According to the Health Extension Work-
with timely initiation of CF [26–28]. ers report, a total of 2319 children aged 6–23  months
Ethiopia designed different programs and strategies lived in the selected kebeles. Proportional allocation was
to improve child feeding practices and nutritional status used to determine the number of children included in
[29–31]. However, inappropriate child feeding practices the study in each targeted kebeles. A systematic sampling
and undernutrition remains a public health problem technique was used to select households with an eligi-
[19]. In Ethiopia, most former research on CF practices ble child. For households with more than one study sub-
were confined to urban areas [23, 24, 27, 28, 32–34], ject, only one was selected using lottery method. When
however majority of the population reside in rural set- mother–child pairs were not available at the time of data
tlements where poor health care access and illiteracy collection three repeated visits were made.
rate is higher [19]. On the other hand, literature is lim-
ited in the Benishangul Gumuz Regional State. There- Data collection tools and procedures
fore, this study aimed to investigate timely initiation of A pretested and structured questionnaires consisting of
CF and associated factors among mothers who had chil- dietary diversity score (DDS) tool was used to collect data.
dren aged 6–23  months in Pawe District, Benishangul Twelve Clinical Nurses and three Health Officers were
Gumuz Regional State, northwest Ethiopia. The finding involved as data collector and supervisor, respectively.
of this study provides information for program design- The English version questionnaire was translated into
ers and implementers to make evidence based decision to Amharic, the native language of the study area, then back
enhance complementary feeding practices. to English by English language and public health experts
to ensure its consistency. The research assistants (data
Methods collectors and supervisors) were trained for 2 days about
Study design and setting interview techniques prior to data collection. The ques-
A community based cross–sectional study was con- tionnaire was pre-tested among 40 mother–child pairs in
ducted in Pawe District from February 01 to March 29, a community with similar socio-demographic profile as
2015. The district is one of the seven districts in Metekel the study area. The clarity, acceptability, and applicability
Zone, Benishangul Gumuz Regional State, northwest of the procedures were evaluated during this pretest.
Ayana et al. BMC Res Notes (2017) 10:335 Page 3 of 8

Operational definition and study variables Results

Complementary feeding practices were assessed accord- Socio‑demographic characteristics
ing to the WHO recommendation [3]. Accordingly, to A total of 785 mother–child pairs were included in the
ascertain timely initiation of CF, a mother was asked to study giving a response rate of 97.6%. The mean (±stand-
report the initial time she gave extra food to her child. ard deviation, SD) age of the mothers was 30  years
She was asked as “When did you first introduce any solid, (±6.52). Nearly three-fourths (72.5%) of respondents
semi-solid or fluid to [child name] in addition to breast were rural residents. The mean (±SD) family size of the
milk”. households was 4.8 (±1.6), and about 73.0% of house-
The standardized DDS tool with 24-h recall was used to holds had  ≥5 family members. Most (63.7 and 56.8%,
qualitatively assess the dietary intake of children. Moth- respectively) of the mothers and fathers had no formal
ers were interviewed to list the food items consumed education (Table 1).
by the child in the previous 24  h preceding the date of
survey. The food items were categorized into seven food Mother’s infant and young child feeding knowledge
groups as grains, roots and tubers; legumes and nuts; and health care utilization
dairy products; flesh foods (meat, fish, poultry and organ The majority (93%) of the mothers knew about the nega-
meats); egg; vitamin-A rich fruits and vegetables; and tive effects of prelacteal feeding. Three quarter of the
other fruits and vegetables [34]. Considering the stand- mothers knew about the benefit (78%) and the appro-
ardized minimum acceptable DDS [5], a child with DDS priate time to initiate CF (72.0%). However, only 10.7%
of  ≥4 was categorized as having good dietary diversity, correctly responded about the minimum dietary diver-
while participant with a DDS of <4 was deemed to have sity. Most of (79.2%) the mothers had postnatal checkup,
poor dietary diversity. while 65.1% received counseling about CF during their
Mothers IYCF knowledge was determined using six postnatal visit Table 2).
knowledge item questions which were adopted from the
WHO key IYCF indicators [3]. Accordingly, respond- Breastfeeding and complementary feeding practices
ents were asked about the health benefit of CF, appro- Considerably high proportion of (96.9%) children were
priate time for initiation of additional/complementary breastfed at least once in life, and 84.7% were breastfeed-
food, the minimum acceptable dietary diversity and meal ing at the time of data collection. More than two-third
frequency, the dangers of prelacteal feeding, and bottle (68.6%) of the mothers initiated breastfeeding within 1 h
feeding. Then, if the mothers correctly answer three or after birth. Prelacteal feeding was detected in 15.9% of
more of the above knowledge questions, she was consid- children (Table 2).
ered as having a good knowledge, otherwise, she had a From the total interviewed mothers, about 61.8% [95%
poor knowledge. CI 58.2, 65.4] of them started CF at the infant’s sixth
month, whereas about 22.5 and 6.5% of mothers intro-
Data analysis duced CF before and after the sixth month, respectively.
Data were entered into EPI-info version 3.5.3 and ana- About 67.7, 52.6, and 32.7% of children aged 6–8, 9–11,
lyzed using the Statistical Package for Social Sciences and 12–23  months fed with the minimum acceptable
(SPSS) version 20. Descriptive statistics, including fre- and age appropriate meal frequency, respectively. One
quencies and proportions, were used to summarize the quarter (23.7%) of children had good dietary diversity
study variables. A binary logistic regression was used to (Table  2). One-third (35.2 and 35.3%, respectively) of
identify the factors associated with timely initiation of children consumed complementary food made from
complementary feeding. The bivariable analysis was car- starchy staples and dairy products. However, only 15% of
ried out for all independent variables with the outcome children ate meat (Fig. 1).
variable, and a p value of <0.2 was used as variable selec-
tion criteria. Thus, variables with a p value of <0.2 in the Factors associated with timely initiation of complementary
bivariable analysis were fitted into multivariable logistic feeding
regression model to control the possible effect of con- The result of bivariable analysis showed that, place of res-
founders. The strength of association was measured idence, marital status, number of children under 5 years,
by odds ratios with a 95% confidence interval. Both the possession of a TV or radio, and postnatal checkup were
crude odds ratio (COR) and adjusted odds ratio (AOR) significantly associated with timely initiation of CF. How-
were reported. Variables with a p value of  <0.05 in the ever, only place of residence and postnatal checkup were
multivariable logistic regression model were considered significantly and independently associated with timely
as significant factors. initiation of CF. With this regard, the higher odds of
Ayana et al. BMC Res Notes (2017) 10:335 Page 4 of 8

Table 1 Socio-demographic characteristics of  children Table 1  continued

and  their parents in  Pawe District, northwest Ethiopia,
Characteristics Frequency Percent
2015
 Primary school (1–8) 198 25.2
Characteristics Frequency Percent
 Secondary school and above 141 18.0
Place of residence Mother’s age
 Urban 215 27.4  15–24 114 (14.5)
 Rural 570 72.6  25–34 410 (52.2)
Sex of the child  35–46 261 (33.3)
 Male 385 49 Father’s employment status (n = 667)
 Female 400 51  Farmer 570 85.4
Age of the child (in months)  Otherc 97 14.7
 6–11 251 32.0 Possession of TV or radio
 12–17 502 63.9  Yes 83 10.7
 18–23 32 4.1  No 702 89.3
Birth order of the child Average monthly income
 1st 175 22.3  <999 584 74.4
 2nd–3rd 513 65.4  1000–2499 113 14.4
 4th and above 97 12.3  ≥3000 88 11.2
Birth interval in years (n = 610) a
  Children at first birth order or without an elder child
a b
 No birth ­interval 175   Oromo, Shinasha, Hadiya, Kumbata, and Tigre
c
 1 81 13.3   Governmental employee and daily laborer
 2–3 394 64.6
 ≥4 135 22.1
Ethnicity timely initiation of CF was noted among mothers who
 Amhara 446 56.7 lived in the urban settlements [AOR = 2.11, 95% CI 1.47,
 Agew 96 12.5 3.02] and had postnatal checkup [AOR  =  1.68, 95% CI
 Gumuz 71 9.0 1.15, 2.45] (Table 3).
 Otherb 172 21.8
Religion Discussion
 Orthodox 450 57.3 WHO designed different strategies to achieve optimal
 Muslim 169 21.3 implementation of CF practice (≥80%) in the last couple
 Protestant 146 18.6 of decades [2, 10, 12, 35]. Ensuring optimal coverage of
 Catholic 18 2.3 appropriate CF has special importance for low and mid-
Family size dle income countries, including Ethiopia, where majority
 ≤5 573 72.9 of children are suffering from undernutrition and related
 >5 212 27.1 consequences [19, 22].
Number children under 5 years This study illustrated that, the coverage of timely initia-
 One 174 22.2 tion of CF was 61.8%. The prevalence was slightly higher
 Two 211 26.8 than the 2011 EDHS report (51%) [19] and other district
 Three to five 400 51 level reports in Ethiopia: Axum (52.8%) [32] and Kamba
Mother’s marital status (54.4%) [23]. However, the finding was lower than the
 Currently married 669 85.2 WHO recommendation for good practice of CF (≥80%)
 Currently unmarried 116 14.8 [35] and the study reports of other developing countries,
Mother’s educational status such as India (77.5%) [36] and Nepal (87.3%) [37]. This
 No formal education 500 63.7 difference could be explained by higher maternal literacy
 Primary school (1–8) 174 22.2 rate and utilization of institutional delivery in the latter
 Secondary school and above 111 14.1 study areas, which are the main fertile grounds to step-
Mother’s employment status up mothers’ confidence in challenging the community
 Housewife 671 85.5 attitude towards inappropriate feeding practices. The
 Employed 114 14.5 previous researches also illustrated that mother’s educa-
Father’s educational status tion was positively associated with timely initiation of CF
 No formal education 446 56.8 [38–41].
Ayana et al. BMC Res Notes (2017) 10:335 Page 5 of 8

Table 2  Maternal health care and  child feeding practices

100%
in Pawe District, northwest Ethiopia, 2015 90%
80%
Characteristics Frequency Percent
70%

Proporon
60%
Antenatal care visit
50%
 Yes 445 56.7 40%
 No 340 43.3 30%
20%
Number of antenatal care visit (n = 445)
10%
 1–3 238 53.5 0%
 ≥4 207 46.5 Starchy Dairy Legumes Other fruit Egg Vitamin-A Meat
staples product and rich fruit
Place of delivery vegetable and
vegetables
 Home 537 68.4
Food groups
 Health institution 248 31.6
Fig. 1  Proportion of children (6–23 months) who consumed indi-
Postnatal checkup vidual food groups in the previous 24 h preceding the date of survey,
 Yes 622 79.2 Pawe District, northwest Ethiopia, 2015
 No 163 20.8
­ F* (n = 622)
Postnatal counseling about C
 Yes 405 65.1 The result of multivariate analysis showed that moth-
 No 217 34.9 ers postnatal checkup enhances the odds of timely initia-
Mother’s IYCF knowledge tion of CF. The result was consistent with other reports
 Good knowledge 422 53.8 of both developed and developing countries [23, 42–46].
 Poor knowledge 363 46.2 In fact, postnatal checkup is an important platform to
Ever breast feed improve mothers’ knowledge and change unfavorable
 Yes 761 96.9 attitude towards implementation of appropriate child
 No 24 3.1 feeding practices. These positive effects mainly oper-
Initiation of breast feeding (n = 761), h ate through child feeding counseling and behavioral
 ≤1 522 68.6 change and communication interventions [36]. Number
 >1 239 31.4 of researches affirmed favorable effect of mother’s IYCF
Breast feeding status during the survey (n = 761) knowledge on implementation of appropriate CF prac-
 Yes 665 84.7 tices [47–52].
 No 96 15.3 Furthermore, the increased odds of timely initiation of
Prelacteal feeding (n = 704) CF were found among urban mothers compared to the
 Yes 121 15.9 rural dwellers. Similar findings were also reported by the
 No 640 84.1 earlier local studies [24, 34, 53]. In Ethiopia, the level of
Type of prelacteal food given (n = 122) maternal health care utilization varies with residence,
 Butter 75 62 in which mothers living in the urban settlements were
 Cow milk 73 60.3 found with high level of service utilization [19]. These
 Water and sugar 72 59.5 disparities in utilization of basic health cares could ease
 Othersa 81 67 access to information on appropriate child feeding prac-
Bottle feeding tices which ultimately improves the likelihood women
 Yes 318 40.5 adherence to appropriate IYCF recommendations [20,
 No 467 59.5
54].
Initiation of complementary feeding
This study showed complementary feeding practice of
 Timely initiation (at sixth month) 485 61.8
children in the predominantly rural population of north-
 Early initiation (before sixth month) 249 31.7
west Ethiopia where limited scientific evidences are
 Late initiation (after sixth month) 51 6.5
available. Moreover, efforts, including adequate training
Dietary diversity
and frequent supervision, were made improve the qual-
 Poor 599 76.3
ity of the data. However, the study is not free from some
 Good 186 23.7
limitations. As an illustration, there is a chance to com-
mit recall bias hence the measurement of some variables
* Complementary feeding
a
(child feeding practice) depends on mother’s recall.
  Formula milk, plain boiled water
Ayana et al. BMC Res Notes (2017) 10:335 Page 6 of 8

Table 3  Factors associated with timely initiation of CF among mothers who had children aged 6–23 months in Pawe Dis-
trict, northwest Ethiopia, 2015
Variables Timely initiation of CF
Yes No Crude odds ratio (95% CI) Adjusted odds ratio (95% CI)

Sex of the child

 Female 247 138 1.00
 Male 238 162 0.82 (0.62, 1.10)
Place of residence
 Rural 325 245 1.00 1.00
 Urban 160 55 2.20 (1.55, 3.11)* 2.11 (1.47, 3.02)*
Mother’s marital status
 Currently married 424 245 1.56 (1.10, 2.32)*
 Currently unmarried 61 55 1.00
Family size
 ≤5 members 364 209 1.31 (0.95, 1.81)
 >5 member 121 91 1.00
Number of children under 5 years
 1 103 71 0.66 (0.47, 0.94)*
 2 145 66 1.00 (0.70, 1.44)
 3–5 237 163 1.00
Birth order of index child
 1st 104 71 1.22 (0.74, 2.01)
 2nd–3rd 328 185 0.83 (0.58, 1.18)
 ≥4th 53 44 1.00
Possession of TV or radio
 No 66 17 1.00
 Yes 419 283 0.38 (0.22, 0.66)*
Postnatal checkup
 Yes 408 214 2.13 (1.5, 3.02)* 1.68 (1.15, 2.45)*
 No 77 86 1.00 1.00
* p < 0.05

Conclusions Authors’ contributions

Conceived and designed the experiments: DA AT AF. Performed the experi-
Complementary feeding practice was sub-optimal in ments: DA AT. Analyzed the data: AT DA. Wrote the paper: DA AT HW AF.
Pawe District. Mothers postnatal checkup and urban Approved the proposal with some revisions: AT DA AF HW. All authors read
residence were significantly associated with timely ini- and approved the final manuscript.
tiation of complementary feeding. As a result, increas- Author details
ing the coverage of postnatal care utilization is crucial 1
 Department of Nursing, Pawe Health Science College, Pawe District, Ethiopia.
2
to implement appropriate complementary feeding prac-  Department of Human Nutrition, Institute of Public Health, College of Medi-
cine and Health Sciences, University of Gondar, Gondar, Ethiopia. 3 Depart-
tices. Standardizing the basic health care elements, ment of Health Service Management and Heath Economics, Institute of Public
IYCF counseling and behavioral change communication Health, College of Medicine and Health Sciences, University of Gondar,
interventions, in postnatal care package are also critical Gondar, Ethiopia.
in addition to increasing the service utilization. Further- Acknowledgements
more, special attention needs to be given for the rural The authors would like to express their sincere gratitude to those mothers
mothers. for their willingness and positive cooperation for being part of our study. The
authors’ heartfelt thanks will also go to Benishangul Gumuz Regional State for
the financial support of this study.
Abbreviations
Competing interests
COR: crude odds ratio; AOR: adjusted odds ratio; WHO: World Health Organiza-
The authors declare that they have no competing interests.
tion; CF: complementary feeding; EDHS: Ethiopia Demographic and Health
Survey; IYCF: infant and young child feeding; DDS: Dietary Diversity Score; SD:
Availability of data and materials
standard deviation; TV: television.
Data will be available upon request from the correspondence authors.
Ayana et al. BMC Res Notes (2017) 10:335 Page 7 of 8

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Not applicable. tion of complementary feeding among children aged 6–24 months in
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lished maps and institutional affiliations. mentary feeding and associated factors among 6 months to 2 years
young children, in Kamba Woreda, South West Ethiopia: a com-
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