Background

During the first six months of a child’s life, breastfeeding is adequate to support its nutritional needs. However, after six months, the child should start to be fed nutritious and safe complementary foods [1–3]. World Health Organization (WHO) recommends exclusive breastfeeding till 6 months of age, introduction of complementary feeding at 6 month while continuing breast-feeding up to 2 years or beyond [1]. Complementary feeding is a process of starting additional food when breast milk alone is insufficient to meet the nutritional requirements of the child and therefore, other foods and liquids are needed along with breast milk or breast milk substitute [1]. The first two years of a child’s life is the most important window of opportunity to prevent undernutrition and its long term adverse consequences such as impaired cognitive development, poor achievement in education and low economic productivity [2].

WHO [3] has developed four indicators to guide complementary feeding of young children. The indicators include: (1) timely introduction of complementary feeding; (2) minimum dietary diversity(feeding the child at least four or more varieties from the seven standard food groups for children aged 6–23 months); (3) minimum meal frequency (feeding the child a minimum of two or three meals with one to two snacks and three or four meals with one to two snacks per day, respectively for breastfed infants of age 6–8 and 9–23 months, and provision of milk products at least twice a day for non-breastfed infants of age 6–23 months); and (4) minimum acceptable diet (a composite indicator of minimum dietary diversity and minimum meal frequency.

The government of Ethiopia designed different strategies and programs to improve infant and young child feeding practices [4–7].The strategies and programs align with WHO’s recommendations as mothers or caregivers are advised to initiate complementary feeding when the child reaches 6 months and children to be fed energy-rich, nutrient-rich, locally available and affordable foods such as thick cereals with added oil or milk, fruits, vegetables, pulses, meat, eggs, fish, and milk products.

Although breastfeeding is a common practice among the majority of Ethiopian mothers, the practice of complementary feeding is very poor [7]. For instance, the 2011 Ethiopian Demographic Health Survey indicated that about 49% of mothers initiated complementary feeding before 6 months and only 5.2% children 6–23 months old were given foods from four or more groups [8]. This same study [8] also mentioned that 27% of mothers provided various types of foods including water and butter before 6 months. Introduction of liquid and solid foods before six months increases the risk of diarrheal diseases and is an important cause of infant and young children morbidity and mortality in developing countries [1, 9]. Appropriate complementary feeding has the potential to prevent 6 percent of all under 5 deaths in developing countries [1].

Studies [10–12] from different regions of Ethiopia on appropriate complementary feeding practice reported various magnitudes and determinants. These determinants include child's characteristics (such as child’s age, sex, and birth order), maternal characteristics (such as education level and postnatal care follow up) and family size. However, there is limited evidence in Horro District, Western Ethiopia with respect to complementary feeding practice and its determinants given existing regional differences in culture and food practices in Ethiopia. Therefore, in this study we have collected a cross-sectional data and determined the magnitude of appropriate complementary feeding practice and its determinants in Horro District, Western Ethiopia. The finding will help nutrition programmers to design appropriate intervention to improve complementary feeding practice in the study area.

Methods

Results

Socio-demographic and economic characteristics

A total of 323 respondents participated in the study with a response rate of 99.4%. The mean age of children was 15.04 months ± 4.36 (SD), and the mean age of mothers was 28.90 years with± 6.575(SD). Majority of mothers (67.5%) were farmers and about 40.9% of mothers have attended primary school. Most of the mothers (40.9%) were protestant by religion and all of them were Oromo (100%) by ethnicity (Table 1).

Download:

• PPT
  PowerPoint slide
• PNG
  larger image
• TIFF
  original image

Table 1. Socio-demographic and economic characteristics of respondents, Horro district, Western Ethiopia, 2016.

https://doi.org/10.1371/journal.pone.0244277.t001

Health care related characteristics

Majority of study participants (84.5%) had antenatal care follow up at least once during their last pregnancy. About 53.6% of mothers gave birth to their current child at health institution and 42.1% of mothers had received postnatal care at least one time. Among study participants, 80.5% had received advice on complementary feeding (Table 2).

Download:

• PPT
  PowerPoint slide
• PNG
  larger image
• TIFF
  original image

Table 2. Health care related characteristics of respondents, Horro district, Western Ethiopia, 2016.

https://doi.org/10.1371/journal.pone.0244277.t002

Complementary feeding practice

Table 3 shows complementary feeding practice of the respondents. Among the participants, 21.4% started complementary feeding before 6 months; 60.4% of them started at 6months and 18.2% started later after 6 months. Of the 323 participants enrolled in the study, 95.4% had ever practiced breastfeeding. The overall prevalence of children who had received minimum dietary diversity was 15.8%. Almost half of the children (51.4%) had received the minimum meal frequency and 10.5% of them received the minimum acceptable diet. The overall prevalence of appropriate complementary feeding practice in the study area was 9.91%.

Download:

• PPT
  PowerPoint slide
• PNG
  larger image
• TIFF
  original image

Table 3. Complementary feeding practice of mothers, Horro district, Western Ethiopia, 2016.

https://doi.org/10.1371/journal.pone.0244277.t003

Table 4 presents the seven food groups recommended by WHO for children 6-23months old. In this study, grains, roots & tubers were the most common food items consumed by children (97.8%) followed by legumes & nuts (64.7%). On the other hand, flesh foods (15.2%) and vitamin A—rich fruits & vegetables (13.9%) were foods less offered to children in the study area. The proportion of food items consumed by children increased with age of the child; children in the age group of 6–11 months were offered less variety of foods compared to children in the age group of 18–23 months.

Download:

• PPT
  PowerPoint slide
• PNG
  larger image
• TIFF
  original image

Table 4. Types of foods given to children age 6–23 months, Horro district, Western Ethiopia, 2016.

https://doi.org/10.1371/journal.pone.0244277.t004

Determinants of appropriate complementary feeding practice

Both bivariate and multivariate analyses were performed to identify determinants of appropriate complementary feeding practice (Table 5). The bivariable logistic regression analysis revealed the presence of association between appropriate complementary feeding practice and residence, age of child, place of birth, educational status of mother, educational status of father, occupational status of mother, PNC follow up and child’s birth order.

Download:

• PPT
  PowerPoint slide
• PNG
  larger image
• TIFF
  original image

Table 5. Bivariate and multivariate logistic regression analysis.

https://doi.org/10.1371/journal.pone.0244277.t005

In multiple logistic regression analysis, only three variables were significantly associated with appropriate complementary feeding; child’s age, mother’s educational status and child’s birth order. Children with age category of 6-11months were 80.5% times less likely to be fed appropriately than those with age category of 18–23 months [AOR = 0.195;95% CI:(0.045, 0.846)]. Those mothers who had no formal education were 88.5% times less likely to practice appropriate complementary feeding than those who had educational status above secondary school [AOR = 0.115;95% CI: (0.002,0.290)]. Besides, mothers who gave birth for the first time were 72.9% times less likely to practice appropriate complementary feeding than those mothers who gave birth for the third time and above [AOR = 0.271:95% CI:(0.011,0.463)].

Discussion

The magnitude of appropriate complementary feeding practice in the study area was 9.91%. This is almost similar with studies reported from Northern and Southern Ethiopia [10, 11].However, the result was lower than a study reported from Northern Ghana [13]. Our finding shows that most of the mothers did not practice appropriate complementary feeding although the majority of mothers responded that they have got counseling on complementary feeding. Effective social and behavior change communication should be therefore designed and implemented to improve the situation.

In this study, only 60.4% of mothers had initiated complementary feeding at the 6^th month of the child’s age as recommended by WHO [3]. This result was consistent with findings reported from Eastern Ethiopia [12] but higher than the national prevalence [8]. On the other hand, the result was lower than studies reported from Northern (79.7%) [10] and Southern (72.5%) Ethiopia [11]. About 40% of mothers in our study started complementary feeding either early before 6 months or later at seven month or beyond. Studies indicated that both early and late initiation of complementary feeding could result in deterioration in physical growth of infants and children and predisposes them to various infectious diseases which further exacerbate their nutritional status [10, 11]. Our finding thus calls for the need to address the problem effectively in the region to reduce the risk of growth faltering among infants and children in the study area.

About 51.5% of children had the minimum meal frequency and this is similar with a study done in two rural zones of Ethiopia [14]. However, this magnitude was lower than those reported from Southeast Asian countries such as Sri Lanka [15], Bangladesh [16] and Nepal [17]. This variation might be due to the low economic status of mothers as most of the mothers included in this study had monthly income <40 USD. Besides, the majority of mothers were farmers and work away from home which could be a challenge to exercise appropriate child care practices. Children should get the minimum number of meals per day to increase the probability of reaching the required levels of energy and micronutrient intakes. As such, for healthy breastfed infants, complementary foods should be provided 2–3 times per day at 6–8 months of age, 3–4 times per day at 9–11 and 12–24 months of age, with additional nutritious snacks offered 1–2 times per day as desired [18, 19].

Our study showed that only 15.8% of children in the study area have got the minimum dietary diversity. This finding is almost similar with studies reported from Northern Ethiopia [10] and India [20]. However, the result was lower than studies reported from two zones of rural Ethiopia [14] and other countries such as Sir Lanka [15], Bangladesh [16], Nepal [17], Kenya [21], Northern Ghana [13] and Tanzania [22]. This low proportion of dietary diversity in the study area might be due to socio economic factors and lack of awareness by mothers on the importance of diversifying diet in feeding children.

The proportion of children who received the minimum acceptable diet was 10.5%. Our result is similar with findings reported from Northern Ethiopia [10], two rural zones of Ethiopia [14] and Tanzania [22], but higher than the national proportion [8]. On the other hand, result was lower than findings reported from Northern Ghana [13], Sir Lanka [15], Bangladesh [16] and Nepal [17]. Our finding shows that children in the study area are not getting adequate energy and nutrients appropriate for their age.

Our study revealed that the proportion of appropriate complementary feeding practice has increased as educational status of mothers increased. This finding was in line with studies done in Northern Ethiopia [10] and Northern Ghana [13]. Mothers with no formal education were not practicing appropriate complementary feeding and this was consistent with findings reported from other countries; India [20], Nairobi [21], Tanzania [22], Indonesia [23], Sir Lanka [15], Bangladesh [16] and Nepal [17].

Children within the age group of 6-11months were less likely to be appropriately fed as compared to children in the age group of 18–23 months. This result was consistent with findings reported from Nepal [17], Northern Ghana [13], Tanzania [22] and Indonesia [23]. This might be due to the misunderstanding among mothers that young children cannot digest foods like meat, eggs as well as fruits and vegetables. Therefore, emphasis should be given on the need for improving the dietary quality of complementary foods such as inclusion of animal source foods as well as vitamin A rich vegetables and fruits in the diet of children.

Mothers who gave birth for the first time were less likely to practice appropriate complementary feeding than those who gave birth more than three times. Although lack of experience could be one of the reasons for this, the situation could have been averted if appropriate messages on child care practices were given to mothers during their antenatal as well as post natal care visits.

Our study had two major limitations. The cross sectional nature of the study prevents it to establish a cause and effect relationship. Though a number of measures were taken, there might be a possibility to recall bias some variables such as time to introduction of complementary foods and type of foods given to the child the day before data collection.

Conclusion

This study showed that only one tenth of mothers in the region were practicing appropriate complementary feeding. This may have a negative impact on the subsequent growth and development of children. Determinants that consistently associated negatively with appropriate complementary feeding practice in the study area were age of the child specifically lower age, birth order and mother’s education. Interventions on appropriate complementary feeding should therefore target uneducated mothers, mothers who gave birth for the first time and those with young children.

Supporting information

Acknowledgments

We are grateful to Horro District Health Office for facilitating the research process by timely writing support letters. Our special thanks also go to data collectors and study participants.