Knowledge, Attitude and Practice Towards Exclusive Breast Feeding Among Inhabitants of Ginjo Guduru Kebele, Town, Oromia Region,

: Appropriate feeding practices are fundamental importance for the survival, growth, development and health of the infant and young children. However; exclusive breastfeeding remains a challenge because of many factors. It was suggested that mother's knowledge, attitude and practice determines the effectiveness of exclusive breastfeeding. This research is a cross-sectional study aimed to assesses mother's knowledge, attitude and practice towards optimal breastfeeding among Ginjo Guduru kebele. The survey was conducted from June 29-July30, 2018, from a total of 315 mothers who had children under one (1) year age, 190 mothers were selected using simple random sampling. Structured pre-tested questionnaires, as well as the in-depth interview, was used to collect the data on the socio-economic, demographic characteristics, knowledge attitude and practice towards exclusive breastfeeding. Among mothers studied about 73.94% had good knowledge of effective breastfeeding, 63.99% of mothers had a positive attitude on effective breastfeeding, and 69.69% had a good practice of effective breastfeeding. About 24.06% of mothers had poor knowledge of effective breastfeeding, approximately 36.11% of mothers had a poor level of attitude on effective breastfeeding, and about 31.31% of mothers had a poor practice of effective breastfeeding. Health service delivery staffs Policymakers, administrators and Non-governmental organisation collaborates to draw strategies to enhance the awareness of mothers about effective breastfeeding.


INTRODUCTION
The practice of lactation on the earth dated back to more than 100 million years ago and continued to the time of Homo sapiens which existed for about 40,000 years ago. Also, wet nursing to lactate the child of the kings was appeared at about 200 years B.C. as a human being is the only in whom the natural and the most practical method of breastfeeding is practised [1]. Effective breastfeeding is considered as a crucial part in the strategy to improve child health. This is because malnutrition contributes to 54% of the underlying cause of fewer than 5 years old children mortality [4][5][6]. Thus, breastfeeding has been found as vital nourishment in strategies to improve child health. But the practice of breastfeeding nowadays is getting down. This is because the use of artificial substitutes of breast milk or bottle-feeding has become widespread to the world recently [2].
Breastfeeding is a nearly universal practice in Ethiopia. Studies show that about 96% of children born breastfed at some time and the proportion of children ever breastfed ranges from 93% in Addis Ababa to 99% in Harari irrespective of other backgrounds. Type of assistant during delivery and place of delivery have *Address correspondence to this author at the Department of Biology (Human Anatomy), College of Natural and Computational Science, Bonga University, Bonga, P.O. Box 334, Ethiopia; Tel: +251474524510, +251474524; E-mail: gebhabtamu@yahoo.com found to influence early breastfeeding practices. Early initiation of breastfeeding is more common among children whose mothers were assisted at delivery by a trained traditional birth attendant and among children delivered at home [3]. Also, it was found that the sociodemographic features of the population, such as being dwellers of city or rural area and educational status of mothers are other variables found to affect the effective breastfeeding practice. It was found that rural or illiterate mothers begin breastfeeding within a few hours from delivery compared to literate mothers [5].

Statement of the Problem
Studies show that about 10 million children under the age of five years die per year and majorities from developing countries. In sub-Saharan Africa, where almost half of all deaths in children aged less than five occurs, the decrease in mortality rates currently sluggish and in some countries the mortality rates have even increased. As this was a devastating problem, the issue has got attention so that Millennium developmental goal number four is to reduce child mortality by 2/3 in 2015 [5]. The causes of the change in child survival are many and include rising poverty, fragile health systems, HIV/AIDS, and malnutrition. Malnutrition is estimated to be the underlying causes of 54% of under the age of 5 years children mortality [4][5][6].
Appropriate feeding practice is one of the fundamental uses for the survival, growth, development, health, and nutrition of infants and young children. It is argued that the promotion of EBF is the most effective child health intervention currently feasible for implementation at the population level in low-income countries. It is also found that EBF could lower infant mortality by 13% [7]. Although the role of EBF in reducing infant mortality is invaluable, most women don't practice EBF for the recommended 6 months [8][9][10]. In Ethiopia, despite the universal practice, breastfeeding is not effective.
In Ethiopia, the increased use of formula feeding by mothers, particularly in urban and semi-urban areas is considered one of the leading causes of its flexibility and ease to use, freeing them to work. Others are convinced by the aggressive marketing campaign of commercial formula companies and by the appeal of modernity that bottle feeding has come too represented. Most poor mothers have no safe water to mix with formula and how problems to maintain bottle sterility properly, and often dilute the formula to make it last longer. These actions increase the likelihood of bacterial contamination and reduce the nutritional benefits of the products [11][12][13].
This study aims to collect baseline information about current knowledge, attitude and practice related to feeding of infants with a special focus on effective breastfeeding. This information is intended to assist in designing intervention strategies to improve the practices that will be included in the result.

General Objective
To assess the knowledge, attitude, the practice of exclusive breastfeeding among inhabitants of Ginjo Guduru Kebele.

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To determine the mothers' knowledge of effective breastfeeding.

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To identify influencing factors of the mother on breastfeeding of their child.

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To identify mothers' attitude towards effective breastfeeding.

Description of Study Area
The study was conducted in Ginjo Guduru kebele, Jimma town. It is located 2km from Jimma University,

Study Design
A cross-sectional community-based survey was conducted to assess mothers KAP towards exclusive breastfeeding among inhabitants of Ginjo Guduru kebele, June 29-August 1, 2017.

Population
The study population was all of the mothers who have children less than one year in Ginjo Guduru kebele. The representative samples of 190 mothers who have children less than one year.

Sample Size and Sampling Technique
The sample size was estimated using the sample size determination formula for a single population proportion. Since there were no previous studies which estimate the prevalence of non-effective breastfeeding in the area, prevalence level that estimates maximum sample size/50%/ marginal error(d) 0.05, non-response rates 10%, 95% confidence certainty and alpha 0.05 was considered, based on these assumptions, a total sample size of 190 was calculated using formula indicated below.
Since the total population is less than 10,000, the final sample size will be calculated by applying the population correction formula. viii. Good practice score > 60% ix. Poor practice score < 60%

Key Terms
Complementary feeding: Provision of other foods or Liquids along with breast milk Colostrum's: special milk that secreted in the first 2-3 days after delivery Early weaning: Supplementation of food in addition to breastfeeding, started before the age of 4 months.
Exclusive breastfeeding: means optimal breastfeeding from birth to the first 6 months Extended Family: Families with additional members other than the mother-father, and children Meconium: the first stools of a newborn baby which are sticky and dark green.
Nuclear Family: Families made up of only parents and children.
Post-Partum: is the period of 6-12 weeks after delivery.

Data Collection Procedure and Instrument
Data were collected by the trained 6 th -year medical student through interviewing each participant from the households to be selected using a structured questionnaire.

Data Processing and Analysis
The collected data were checked for completeness of information and consistency. The data was compiled, analysed and presented using tables and percentage. A scientific calculator was used for the mathematical operation of numerical variables. The computer was used for writing and editing. Chi-Square test was used to determine the level of significance and association between dependent and independent variables.
The results were compared with regional, national and WHO results.

Quality Control Measure
The questionnaire was checked for its clarity, completeness, reliability, consistency, sensitivity, time and patterns of response were used. The training was given for data collectors on the instrument and data collection procedure. Where there be any difficulties during data collection, things were explained, discussed and briefed to respondents by their mother lang-uages. Daily monitoring of the process and feedback on each day performance at the end of working hours was done. Then correction was made accordingly. Table 1, all the Socio-demographic feature of 190 mothers as a sample population from the As depicted in Table 2, among women of childbearing ages, about 92.63% had practised breastfeeding. The remaining women's have no practice. About 74.74% of mothers had health education, while the remaining mothers have no health education yet. The mass media have played the most significant role in awareness creation that account for 49.47% whereas books and information from health institution account for about 12.63% and 11.58% respectively. Majority of mothers evaluated their general health status as good and very good, accounting for 44.21% and 33.16% respectively. About 3.16% of mothers evaluated themselves as very bad.

According to
As presented in Table 3, the knowledge assessment shows that: about 92.63% of them knew the importance of breastfeeding and 81.05% of mothers knew that breast milk alone is important for the newborn. The importance of water and butter is suggested by 10.53% and 6.32% of mothers respectively. Concerning the duration of exclusive breastfeeding, about 82.1% know that child should be breastfed from 4-6 months while 10% know the duration to be 4 months and the remaining prefer more than 6 months. About 92.63% of the mothers knew about breastfeeding as it did not cause harm to the child. The reaming said it harm the child. Concerning the knowledge of bottle feeding, 46.84% of the mothers said it did not cause harm to the child, 53.16% knew bottle-feeding cause harm to the child. Concerning to the time to start complementary feeding, about 81.05% did not start before four months. About 18.95% started before four months. The reason they started before four months as they said was their breastfeeding was not sufficient alone in about 8.95%, the others said breastfeeding was not sufficient in about 4.74%. 3.68% of mothers said due to child refusal. Regarding the duration of exclusive breastfeeding, 55.26% of the mothers exclusively breastfeed for six months. About 15.79% exclusively breastfeed for four months.
Concerning the attitude of mothers towards KAP of exclusively breastfeeding in (Table 4) as usual, 190 of childbearing age women interviewed. Among these, 55.79% preferred to feed their babies in the first four months with breast milk alone. About 32.63% prefer to feed with breast milk and cow milk together. The remaining 7.37% preferred to feed with breast milk and formula milk. 58.42% of mothers agreed as exclusively breastfeeding for the first six months was advantageous for the babies. The others had ideas of neutral and disagreed, which accounts for 26.84% and 14.74% respectively. Concerning colostrum, about 65.26% said colostrum should not discard, and 9.47% agreed on the ideas, while the remaining ones were neutral. About 55.26% of mothers said that exclusively breastfeeding is sufficient for the baby in the first four months. Other said it was not sufficient as cow milk and formula milk which accounts for about 16.84%. Approximately 93.16% of the mothers said their babies' breastfed as frequent as they need, and the remaining said no.     Regarding the attitude of bottle-feeding, about 64.74% of mothers said it was useful if breastfed was impossible, 22.11% of the mother said it was useful we breastfed or not. The remain told it was not important. Regarding the opinion of mothers on breastfeeding as mothers of today, about 54.21% of mothers said it was natural and appropriate, about 23.68% said it was outmoded. About 13.16% told it disfigures the women's shape. About 6.84% said it looks her old.
Concerning the practice of KAP on exclusive breastfeeding of mothers of childbearing age in the kebeles ( Table 5), among 190 about 85.26%% started to breastfeed within one hour of delivery, whereas 10.53% started after one hour. About 47.9% of the woman breastfed their child 8-10 times per day. At the same time, 33.16% breastfed for greater than 10 times per day. The remaining one breastfed their child less than 8 times per day. About 92.11% exclusively breastfed their babies. Among these, 84.21% exclusively breastfed their babies for the first six months, and about 5.79% of the mother's breastfed for greater than six months. Regarding colostrum, about 76.84% of mothers gave colostrum to their baby, and the remaining didn't do that. The reason they didn't provide is that it seems like dirty and pus in about 13.68% of mothers, the elder child got sick and no opinion which accounts for about 7.37% and 1.05% respectively. The practise of giving the first nutrient for the infant was in approximately 56.84% breast milk, 21.58% water, 11.05% sugar and 6.84% butter.
Regarding the time of cessation of breastfeeding, about 54.74% of the mothers said from 19-24 months. Approximately 24.74% of mothers said from 13-18 months. The remaining said 7-12 months and up to 6 months, which accounts for 12.63% and 5.79% respectively. The reason they stopped breastfeeding was in about 51.59% due to it was the time to stop breastfeeding, in approximately 17.37% their baby didn't eat well, 11.05% was due to decrease inflow of their milk. The others told because they were sick and took drugs in about 7.9%, in about 5.79% due to they got pregnant.
As to the practice of breastfeeding among mothers in the study area ( Table 6), majority of mother's (54.74%) cessation time for breastfeeding practice was 19-24 month for 51.59% of the cases, the time thought to be adequate was the reason for cessation of the practice. Table 7 shows that: type of family childbearing age of mothers, educational status and occupation have a significant association with knowledge of exclusive breastfeeding having P-value < 0.05. In addition to these, child age, ethnicity, religion, monthly income, no of children and marital status have no association with the knowledge toward EBF with P-value > 0.05 As presented in Table 8, except the occupation of mothers which significantly affects the attitude of mothers toward EBF, no other socio-demographic features have an association with the attitude toward EBF.
The age and educational status of mothers in the study area have a significant effect on the practice of EBF. Other socio-demographic features have no association with EBF practice as presented by Table 9.

DISCUSSION
This study showed that the prevalence of exclusive breastfeeding for infant age less than six months is 92.11%. This result is quite higher than the finding from Mekele in 2011 [19], which were 60.8%. Also, this result is high when compared to national prevalence, 2006 (49%) [32], this gap might be related to the majority of mother's are educated and uses mass media and which helped them to practise exclusive breastfeeding. In addition, the reason for this might be the current policy implementation on the use of health extension worker to promote breastfeeding.
Concerning knowledge of EBF, even though there is no recent literature that could be revised on mothers KAP of EBF in the study area, some studies conducted reveal different findings on mother's knowledge, attitude and practices of exclusive breastfeeding. A study conducted on KAP of EBF at Kirkos sub-city  Addis Ababa showed a high percentage of mothers had adequate levels of EBF knowledge, attitude and practices [33]. This study also showed that the majority of mothers had EBF knowledge, attitude and practice, which is similar when compared with study in Kirkos sub-city, 2011 [33].
The timely initiation of breastfeeding found in this study was 85.26%. This finding was high when compared to the study conducted in Asella town, 2009, 74.6% [34]. This difference might be because of the high proportion of mothers awareness increment through mass media, health worker and books which could help them to initiate breastfeeding early.
In this study, mothers were asked about the frequency of breastfeeding. It showed that the appropriate frequency of breastfeeding rate was found to be 47.9%. This finding was lower than the study done in Mekele town in 2011, which was 85.3% [35]. This difference could be explained that in the current study majority of the respondents work outside the home by occupation, so they might have a low chance of staying with their babies.
Regarding the time of cessation of breastfeeding, about 54.74% of the mothers said between 19-24 months, and most of them addressed the reason was they assume this time as adequate for weaning. In Ethiopia, a cross-sectional survey in Adigrat and Tigray shows the majority of mothers stopped breastfeeding when they became sick or pregnant, or their child became ill. More than half of the women decide to discontinue breastfeeding when they become pregnant again [29]. The reason majority of mothers stop adequacy of time secondary to information they got from health institution, mass media and books might.
Like in many other developing countries, the practice of mother giving water to their children in addition to the breast milk was common [36,37]. It is evident that the early introduction of liquids and solids is unnecessary, reduces the duration and frequency of breastfeeding, and increases the risk of infant morbidity and mortality [38,39]. Therefore, such unhealthy behaviour needs to be corrected.
Knowledge is associated positively with the age of the mothers, types of family, educational status and occupation of the mothers. The attitude of the mothers is related to the type of family and occupation. The practice is also related to the age of the mother and education. Regarding attitude, the research done in Santiago California is similar.

CONCLUSION
As noticed from the discussion above the literacy level of mothers and the strength of promotion regarding EBF has direct relation.

RECOMMENDATION
Health service delivery staffs, Policymakers, administrators and Non-governmental organisation should collaborate to draw strategies to enhance the awareness of mothers about EBF. Mothers who deliver in the health institute should have prior knowledge about EBF so that they initiated to breastfeed their child, including the time of initiation immediately after birth. The harmful effect of failure in exclusive breastfeeding and similar large scale study should be conducted in regional and country-level so that the best strategies to achieve EBF practical in Ethiopia.