Abstract
Introduction
Exclusive breastfeeding during the first six months postpartum is essential for preventing unintended pregnancy. Lactational amenorrhea method (LAM) is a safe and effective natural family planning method that provides up to 98% protection when its three criteria are met. Inadequate knowledge of LAM and poor exclusive breastfeeding practices increase the risk of unintended pregnancy. This study assessed the association between exclusive breastfeeding practice and maternal knowledge of LAM and its associated factors among postpartum mothers in Northeast Ethiopia, 2023/24.
Method
An institution-based cross-sectional study design was employed. The study was conducted in four hospitals in Northeast Ethiopia. A total of 607 participants were included, and the study period was from March 2023 to June 30, 2023. Data were collected using standardized, interviewer-administered questionnaires. Multivariable logistic regression model was employed using SPSS version 26. Multicollinearity, sensitivity analysis and Hosmer–Lemeshow goodness-of-fit test were assessed. Variables with p-values less than 0.25 in the bivariable analysis were entered into multivariable logistic regression model to control for potential confounders. Finally, variables with p-values less than 0.05 at 95% CI were considered statistically significant.
Result
The prevalence of good exclusive breastfeeding practice was 68.4% (95% CI: 64.0–72.8%), while good maternal knowledge of the lactational amenorrhea method was 56.0% (95% CI: 50.7–61.2%). Maternal knowledge of LAM was significantly associated with exclusive breastfeeding practice (χ² = 5.378, p = 0.02). Factors significantly associated with exclusive breastfeeding practice included marital status (AOR: 0.5; 95% CI: 0.2–0.9), educational level (AOR: 2.0; 95% CI: 1.3–3.0), and reason for hospital visit (AOR: 0.45; 95% CI: 0.28–0.73). Factors associated with maternal knowledge of LAM were marital status (AOR: 4.0; 95% CI: 1.83–9.0), educational status (AOR: 1.8; 95% CI: 1.16–2.76), age (AOR: 0.42; 95% CI: 0.28–0.63), and hospital level (AOR: 1.5; 95% CI: 1.02–2.17).
Conclusion
Two-thirds of participants had good exclusive breastfeeding practices, and 56% were knowledgeable about LAM. Marital status, educational level, and reason for hospital visit were significantly associated with exclusive breastfeeding practice. Structured postnatal education should be provided across all hospitals to improve exclusive breastfeeding practice.
Clinical trial number
Not applicable.
Keywords: Exclusive breastfeeding practice, Maternal knowledge, Lactational amenorrhea method
Introduction
Lactational amenorrhea method (LAM) is a natural family planning method that relies on exclusive breastfeeding [1]. Breastfeeding is a natural method of supporting birth spacing and regulating fertility. Delaying pregnancy is vital for the health of both the mother and the child [2].
According to World Health Organization, exclusive breastfeeding is one of the most effective preventive interventions to reduce neonatal and childhood morbidity and mortality [3]. Optimal breastfeeding is recommended for the first six months, with continued breastfeeding up to one year [4].
In developing countries, most mothers (88.3%) have low knowledge of the importance of exclusive breastfeeding [5]. The three components for LAM must be fulfilled to protect from pregnancy. These are child age below six month, fully exclusive breast feed and no return of menses [6]. If the three fulfilled, the mother can use lactational amenorrhea method and very effective in protecting unintended pregnancy until six month after birth [1].
In Lagos, 32.1% of mothers recognized the nutritional benefits of breastfeeding, 11.0% identified it as helpful for child spacing, and 6.8% mentioned its role in protecting the child from illness [7].
According to a systematic review and meta-analysis on exclusive breastfeeding practices in East Africa, 55.9% of postpartum mothers practiced exclusive breastfeeding for six months [8]. In Ethiopia, knowledge of the lactational amenorrhea method among postpartum women was low (40.6%). Factors influencing knowledge of LAM were educational level, parity, distance to health facilities, desire for further fertility, counseling on LAM, and hospital delivery [1].
Evidence showed that 39% of mothers in South Africa breastfed exclusively, while 61% practiced mixed feeding. The main reasons for non-exclusive breastfeeding were age, illness, schooling, and work-related burdens. Among HIV-positive women, most (43%) did not breastfeed their infants due to the misconception that breastfeeding could transmit HIV to the child [9].
Exclusive breastfeeding is not only a challenge in developing countries but also in developed countries. In the USA, the main maternal reasons for not continuing exclusive breastfeeding are insufficient breast milk, nipple soreness, and early return to work or school [10].
In China, the rate of exclusive breastfeeding during the postpartum period within six weeks after childbirth was 50.6%. Among mothers who did not practice exclusive breastfeeding, 57% reported stopping due to the perception of insufficient breast milk. Contributing factors to low rates of exclusive breastfeeding during the first six months include cultural influences, maternal age, ethnicity, cesarean delivery, and cultural empowerment [11]. At the individual level, facilitating factors for exclusive breastfeeding include relaxation and low stress, good lactation skills, and support from others [12].
The practice of exclusive breastfeeding in Nigeria was low (31%) [13]. Factors contributing to low exclusive breastfeeding included tertiary education, employment as civil servants, maternal knowledge, and community support [14]. In Mizan Aman town, Ethiopia, the practice of exclusive breastfeeding was also low (26.4%) [15], whereas the majority of employed women in Mecha District, Ethiopia (92.1%), had good knowledge about exclusive breastfeeding. However, only 38.5% and 8.8% of women actually practiced exclusive breastfeeding [16, 17].
According to the 2016 Ethiopian Demographic and Health Survey report, breastfeeding practices were influenced by cultural norms surrounding infant feeding, unequal access to maternal healthcare services, and variations in the implementation of national breastfeeding policies, all shaped by differences in social, cultural, and health system contexts [18].
According to the Health Belief Model, individuals are more likely to adopt a health-related behavior when they perceive themselves as susceptible to a particular condition, recognize the benefits of taking action, and have confidence in their ability to successfully perform the behavior (self-efficacy) [8].
In the context of this study, mothers who are knowledgeable about LAM are more likely to exclusively breastfeed for six months, which not only benefits their infants’ health but also serves as a natural contraceptive method. This knowledge enhances perceived benefits and self-efficacy, motivating mothers to maintain exclusive breastfeeding. Moreover, understanding the barriers to LAM enables women to address challenges effectively and adhere to recommended practices. Evidence shows that higher maternal knowledge of LAM is positively associated with exclusive breastfeeding [9].
The rationale for this study originates from the limited evidence on this topic, despite the high prevalence of malnutrition and unintended pregnancies resulting from inappropriate breastfeeding practices during the early postpartum period. Many postpartum mothers experience unintended pregnancies within six weeks after childbirth due to insufficient knowledge of LAM, the timing of fertility return, and female reproductive physiology. Consequently, these mothers face closely spaced births, social and familial burdens, and increased risks of under-five morbidity and mortality.
This study has important implications for healthcare providers, administrators, policymakers, and researchers. Its findings can inform the development of interventions aimed at improving breastfeeding practices and enhancing maternal empowerment regarding contraceptive choices and infant nutrition by promoting exclusive breastfeeding. Therefore, this study assessed the association between exclusive breastfeeding practices and maternal knowledge of the lactational amenorrhea method, as well as the factors associated with these practices among postpartum mothers in Northeast Ethiopia.
Conceptual framework
The conceptual framework (Fig. 1) depicts the relationship between maternal knowledge of the lactational amenorrhea method (LAM) and exclusive breastfeeding practices. Exclusive breastfeeding is the dependent variable, representing the outcome the study aims to explain. Maternal knowledge of LAM, along with socio-demographic variables, obstetric characteristics, maternal health, and access to healthcare, are treated as independent variables that may influence breast feeding practice. The framework visually illustrates how maternal knowledge and other individual and contextual factors interact to shape the likelihood of exclusive breastfeeding.
Fig. 1.
Conceptual framework illustrating the association between maternal knowledge of the lactational amenorrhea method (LAM) and exclusive breastfeeding practices (adapted from various sources [1, 15, 17])
Research questions
What is the prevalence of exclusive breastfeeding practice among postpartum mothers?
What proportion of mothers are knowledgeable about the lactational amenorrhea method?
Which factors are significantly associated with exclusive breastfeeding practice and maternal knowledge of LAM?
Is maternal knowledge of the lactational amenorrhea method associated with exclusive breastfeeding practice?
Methods and materials
Study setting and period
The study was conducted in selected hospitals in northeast Ethiopia, including Dessie, Debre Berhan, Woldia, and Kemise hospitals. Dessie Referral Hospital is located in Dessie town, Amhara Region, 401 km from Addis Ababa, and serves more than eight million people. Debre Berhan Referral Hospital is situated in Debre Berhan town, about 130 km from Addis Ababa. Kemise General Hospital is located in Kemise town, 326 km from Addis Ababa, in Oromia Special Zone of Amhara Region and Woldia General Hospital is found in Woldia town, North Wollo Zone, Amhara Region. Currently, these hospitals named as Dessie Comprehensive Specialized Hospital, Debre Berhan Comprehensive Specialized Hospital, Woldia Referral Hospital, and Kemise general hospital.
All selected hospitals provide maternal and child health services, including, postnatal care (PNC), child immunization, labor and delivery services, prevention of mother-to-child transmission (PMTCT) of HIV, as well as other maternal and child health interventions. The study was conducted from March 2023 to June 30, 2023.
Study design
A facility-based cross-sectional study design was conducted.
Population
Source population
All postpartum mothers who utilized maternal and child health services in the selected hospitals of Northeast Ethiopia.
Study population
All selected postpartum mothers who came to the selected hospitals to seek maternal and child health services.
Inclusion and exclusion criteria
Inclusion criteria
Postpartum mothers who sought maternal and child health services at the PNC, child immunization unit, prevention of mother-to-child transmission unit, delivery unit, and under-five outpatient clinics.
Exclusion criteria
Those participants who were seriously ill or mentally incapable during the interview.
Sample size determination
The sample size was calculated using a single population proportion formula, based on the following assumption:
P: a prevalence of 8.8% for adequate maternal knowledge of the lactational amenorrhea method in Tigray region of Ethiopia was used, based on the most relevant local evidence available at the time the protocol was developed [17].
d: margin of error of 5% (0.05) was used, along with a design effect of 1.5 to account for design effect. Post hoc power analysis, based on the observed effect sizes, indicated that the study had over 80% statistical power to detect the observed differences.
Zα/2 (95% confidence level): 1.96
n: Sample size
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The required sample size for this study was calculated to be 568 participants. Nevertheless, as the study was embedded within a larger research project, 607 participants were ultimately enrolled, representing the final sample included in the analysis.
Sampling technique and procedure
A total of four hospitals were selected from Northeast Ethiopia. These hospitals were randomly chosen from four zones in the Amhara region. Proportional allocation of the sample across facilities was determined based on the average monthly client flow at each hospital, ensuring that facilities with higher client volumes contributed more participants. This approach enhanced representativeness and reduced selection bias.
A simple random sampling (SRS) technique was used to select study participants. The sampling frame was constructed from the MCH registration book of postpartum women. To ensure randomness, a daily list of all eligible postpartum women attending each MCH unit was generated. Each participant was assigned a unique number to select participants for inclusion. To prevent including the same participant more than once, each postpartum woman was assigned a unique identifier number, and participant records were cross-checked daily before data collection (Fig. 2).
Fig. 2.
Sampling procedure flowchart showing the association between exclusive breastfeeding practices and maternal knowledge of LAM among postpartum women in northeast Ethiopia
Data collection tools & techniques
A structured, pre-tested, interviewer-administered questionnaire was adapted from the Ethiopian Demographic and Health Survey 2016 and other study conducted in Ethiopia [8, 19]. The questionnaire was initially developed in English and then translated into the local language (Amharic) to ensure that study participants could easily understand it. To verify consistency in meaning and interpretation, the questionnaire was back-translated into English by a language expert.
Maternal knowledge of LAM was assessed using three questions: (a) exclusive breastfeeding with the mother’s milk, (b) presence of postpartum amenorrhea (no return of menses), and (c) infant age under six months. The internal consistency (reliability) of this tool was high, with a Cronbach’s alpha of 0.83. Data were collected through face-to-face interviews conducted after mothers completed their maternal and child health services at five selected MCH units: postnatal care, child immunization, PMTCT, neonatal/child care clinic, and delivery unit. These units provide access to postpartum mothers attending for a variety of health services.
Data collection procedures
Four supervisors holding master’s degrees in public health and eight data collectors with bachelor’s degrees in midwifery were recruited and trained for three days. The training covered the objectives of the study, appropriate approaches to study participants, the relevance of the study, informed consent, confidentiality of information, participants’ rights, procedures for addressing challenges during data collection, timely data collection, and checking completed questionnaires for completeness.
Study variables
Dependent variable
Prevalence of exclusive breastfeeding practice.
Independent variables
Sociodemographic variables: age, marital status, educational status, religion, distance to health facility, place of residence, and reason for health facility visit.
Hospital type: referral or general hospital.
Obstetric characteristics: number of pregnancies, planned number of children, and actual number of children.
Reproductive health characteristics: currently using FP service, and plan to space or limit children.
Maternal knowledge of lactational amenorrhea method.
Data quality control
To ensure the validity and reliability of the data, a structured questionnaire was pre-tested at Boru Meda Hospital using 5% of the sample size. This hospital was not included among the study sites. Additionally, data collectors received three days of training to enhance their knowledge and skills in data collection techniques and procedures, specifically aimed at improving data quality. To obtain informed consent and reliable data, a clear explanation of the study’s purpose and procedures was provided to all participants. This also enabled participants to respond based on an adequate understanding of the research topic, thereby improving data accuracy and usefulness for decision-making by relevant stakeholders. Finally, completed questionnaires were reviewed daily by supervisors, and close monitoring by the principal investigator ensured that all information was collected and recorded properly and in a timely manner. These measures were implemented to maintain overall data quality assurance.
Operational definition
Natural family planning methods
Family planning option for preventing pregnancy that rely on normal physiological changes in the body, particularly the suppression of ovulation, without using artificial contraceptives [20].
Knowledge of the lactational amenorrhea method
Knowledge of LAM as a contraceptive method was measured using three criteria. A binary variable was used in which participants who mentioned all three criteria were classified as knowledgeable, while those who did not were not knowledgeable [1, 17].
Good exclusive breastfeeding practice
It was defined as those women who gave only breast milk to an infant younger than six months, with no additional food or drink, including water. Any deviation from this practice was considered poor breastfeeding practice [21].
Data processing and analysis
Data completeness, double data entry, cleaning, and cross-checking were performed before statistical analysis. The data were coded and entered into EpiData version 3.1 and subsequently exported to SPSS version 26 for analysis. The data analysis focused on assessing associative relationships. Bivariable analysis was conducted to examine the association between each independent variable and the outcome variable. Variables with p-value of less than 0.25 in the bivariable analysis were entered into the multivariable logistic regression model. Multivariable logistic regression was then used to identify factors independently associated with the outcome variable.
Model diagnostic checks were conducted to ensure the validity of the regression models. Multicollinearity was assessed using the variance inflation factor (VIF), and all variables had VIF values below 2, indicating no significant multicollinearity. Model fit was evaluated using the Hosmer–Lemeshow goodness-of-fit test, with (P-value = 0.56) for maternal knowledge of the lactational amenorrhea method and (P-value = 0.42) for exclusive breastfeeding practice, indicated adequate model fit. A chi-square test was used to assess the association between maternal knowledge of LAM and exclusive breastfeeding practice. Moreover, sensitivity analysis was performed using a mixed-effects logistic regression model, including hospital as a random effect.
Descriptive statistics, including means, standard deviations, frequencies, and percentages, were used to summarize the study variables. Data were presented using tables, graphs, and pie charts. Variables that showed statistically significant associations with the outcome variable in the multivariable logistic regression analysis were reported using adjusted odds ratios (AORs) with 95% CI, and p-value of less than 0.05 was considered statistically significant.
Results
Sociodemographic characteristics of respondents
A total of 607 postpartum mothers participated in the study, yielding a 100% response rate. Among the respondents, 464 (76.5%) were aged between 15 and 30 years. The mean age of the participants was 28 years (SD = ± 5). Regarding religion, 330 (54.4%) of the respondents were Orthodox Christians. The majority of participants, 573 (94.4%), were married. Regarding educational status, 252 (41.5%) had attained at least grade one education or higher. Approximately one-third of the participants, 180 (29.7%), traveled more than one hour to reach a health facility for maternal and child health services utilization (Table 1).
Table 1.
Sociodemographic characteristics of respondents on exclusive breastfeeding practice and maternal knowledge of LAM among postpartum mothers in northeast Ethiopia (n = 607)
| Characteristics | Category | Higher hospital (referral hospital) n(%) |
Lower hospital (General hospital) n(%) |
Total n(%) |
|---|---|---|---|---|
| Age(years) | 15–30 | 315(51.8) | 149(24.5) | 464(76.5) |
| 31–50 | 85(14) | 58(9.5) | 143(23.5) | |
| Religion | Orthodox | 240(60) | 90(43.4) | 330(54.4) |
| Muslim | 156(39) | 102(49.2) | 258(42.5) | |
| Protestant | 2(0.5) | 10(4.8) | 12(2) | |
| Catholic | 2(0.5) | 5(2.4) | 7(1.1) | |
| Marital status | Married | 380(95) | 193(93.2) | 573(94.4) |
| Divorced | 15(3.7) | 8(3.8) | 23(3.8) | |
| Widowed | 2(0.5) | 1(0.5) | 3(0.5) | |
| Single | 3(0.8) | 5(2.5) | 8(1.3) | |
| Educational status | Cannot read & write | 66(16.5) | 67(32.4) | 133(22) |
| Primary (grade 1–8) | 177(44.2) | 75(36.3) | 252(41.5) | |
| Secondary (above Grade 9) | 87(21.8) | 42(20.2) | 129(21.2) | |
| College & above | 70(17.5) | 23(11.1) | 93(15.3) | |
| Time taken to reach hospital | < 1 h | 260(65) | 167(80.7) | 427(70.3) |
| ≥ 1 h | 140(35) | 40(19.3) | 180(29.7) |
Obstetrics characteristics of study participants
The majority of participants, 354 (58.3%), had given birth to their most recent child in the last three months. In this study, one-third of the participants, 204 (33.6%), were primiparous (had one child) (Table 2).
Table 2.
Obstetric characteristics of respondents on exclusive breastfeeding practice and knowledge of LAM among postpartum mothers in northeast Ethiopia (n = 607)
| Characteristics | Category | Frequency | Percent |
|---|---|---|---|
| Time since last birth | < 3month | 354 | 58.3 |
| 3-5month | 80 | 13.2 | |
| 6–11 month | 156 | 25.7 | |
| 12–24 month | 8 | 1.3 | |
| > 25 month | 9 | 1.5 | |
| Ideal number of children | 1–3 | 140 | 23 |
| 4 and above | 467 | 77 | |
| Number of living children | 1 | 204 | 33.6 |
| 2 | 162 | 26.6 | |
| 3 | 112 | 18.5 | |
| 4 | 78 | 12.8 | |
| ≥ 5 | 51 | 8.5 | |
| Do you know not exclusively breast feed risk for pregnancy | No | 265 | 43.6 |
| Yes | 342 | 56.4 | |
|
Referral hospital n (%) |
General hospital n (%) |
||
| Breastfeeding practices | Only breast milk | 284(71) | 131(63.2) |
| Breast milk plus other food | 100(25) | 64(31) | |
| Not breast feed | 16(4) | 12(5.8) | |
Cient centered family planning counseling
Out of the 607 study participants, 391 (64.4%) reported that they had received counseling from health care providers at hospitals regarding the health benefits of birth spacing for their own health and their neonate. One-fifth of mother 119 (20%) reported experiencing major problems related to the maternal health care services they received at hospitals (Table 3).
Table 3.
Provider-friendly health services for postpartum mothers in northeast Ethiopia (n = 607)
| Characteristics | Category | Frequency | Percentage |
|---|---|---|---|
| How staff treat the client | Major problem | 119 | 19.6 |
| Minor problem | 130 | 21.4 | |
| No problem | 351 | 57.9 | |
| Do not know | 7 | 1.1 | |
| Provider ask postpartum mother when to get pregnant | No | 235 | 39.6 |
| Yes | 347 | 58.5 | |
| Not remember | 11 | 1.9 |
Prevalence of exclusive breastfeeding practice
In this study, nearly two-thirds of the participants practiced exclusive breastfeeding, with a prevalence of 68.4% (n = 415; 95% CI: 64.0%–72.8%) (Fig. 3).
Fig. 3.
Prevalence of breastfeeding practices among postpartum mothers in northeast Ethiopia
Participants at higher-level hospitals (71%) demonstrated better exclusive breastfeeding practices. Similarly, women with formal education (having attended at least grade one) had better exclusive breastfeeding practices 341 (71.9%) than those who cannot read or write (Table 4).
Table 4.
Cross-tabulation showing the prevalence of exclusive breastfeeding practice in Northeast Ethiopia
| Variables | Exclusive breastfeeding practice | |
|---|---|---|
| Good n(%) | Poor n(%) |
|
| Hospital type | ||
| Referral Hospital | 284(71) | 116(29) |
| District Hospital | 131(63.3) | 76(36.7) |
| Age(year) | ||
| 18–30 | 303(69.8) | 131(30.2) |
| 31–49 | 112(64.7) | 61(35.3) |
| Education | ||
| Can not read and write | 74(55.6) | 59(44.4) |
| Attended Grade 1 and above | 341(71.9) | 133(28.1) |
| Number of children | ||
| Only one child | 151(74) | 53(26) |
| Two and more children | 264(65.5) | 139(34.5) |
Factors associated with exclusive breastfeeding practice among postpartum mother
To identify factors associated with exclusive breastfeeding practice, variables with p-value less than 0.25 in the bivariable analysis were entered into multivariable logistic regression model to control for potential confounders. Parity and antenatal care were omitted from the final model because they were not significant in the bivariable logistic regression analysis, and it was not considered rational to include antenatal care visits for breastfeeding practice. Moreover, a sensitivity analysis was performed using a mixed-effects logistic regression model, which included hospital as a random effect. The results were consistent with the primary analysis and showed no meaningful changes in statistical significance.
Variables that were statistically significant in the multivariable logistic regression analysis included: Postpartum mothers who lived with their sexual partner were less likely to practice exclusive breastfeeding compared to those who did not live with a partner (AOR: 0.5; 95% CI: 0.2–0.9).
Participants who had attended formal education (grade one and above) were twice more likely to practice exclusive breastfeeding than those who had not attended formal education (AOR: 2.0; 95% CI: 1.3–3.0).
Postpartum mothers who visited health facilities for maternal health services were less likely to practice exclusive breastfeeding compared to those who visited for family planning services (AOR: 0.45; 95% CI: 0.28–0.73) (Table 5).
Table 5.
Bivariable and multivariable logistic regression analysis of factors associated with exclusive breastfeeding practice among postpartum mothers in northeast Ethiopia (n = 607)
| Variables | Breastfeeding practice | COR, P-value | AOR, (95% CI) | P-value | |
|---|---|---|---|---|---|
| Good n(%) |
Poor n(%) |
||||
| Marital status | 0.04 * | ||||
| Married (living with partner) | 398(95.9) | 175(91.1) | 0.48, 0.01 | 0.5(0.2, 0.9) | |
| Not living with partner | 17(4.1) | 17(8.9) | 1 | 1 | |
| Educational status | 0.001 * | ||||
| No formal education | 74(17.8) | 59(30.7) | 2,0.000 | 2(1.3, 3) | |
| Formal education (above grade one) | 341(82.2) | 133(69.3) | 1 | 1 | |
| Reason of Hospital visit | 0.001* | ||||
| For other MCH service | 374(90.1) | 152(79.2) | 0.48, 0.001 | 0.45(0.28, 0.73) | |
| For FP service | 41(9.9) | 40(20.8) | 1 | 1 | |
| Time to reach to health facility | 0.15 | ||||
| Less than 1 h | 301(72.5) | 126(65.6) | 0.73, 0.09 | 0.75(0.51, 1.11) | |
| 1 h & above | 114(27.5) | 66(34.4) | 1 | 1 | |
*Statistically significant at p < 0.05, AOR: adjusted odds ratio; COR: Crude odds ratio
Maternal knowledge of Lactational amenorrhea method
In this study, participants who correctly answered all three maternal knowledge questions on the lactational amenorrhea method were classified as knowledgeable, while others were not knowledgeable. The overall proportion of postpartum women with good knowledge of the lactational amenorrhea method was 56% (n = 342, 95% CI: 50.8–61.3%) (Fig. 4).
Fig. 4.
Proportion of postpartum mothers with knowledge of the lactational amenorrhea method in Northeast Ethiopia (n = 607)
Factors associated with maternal knowledge of the lactational amenorrhea method
At the bivariable analysis, four variables had a p-value less than 0.05, while the other two variables p-value greater than 0.05. All six variables were entered into a multivariable logistic regression model. Then, five predictor variables were found to be significantly associated with the outcome variable, with a p-value less than 0.05 and a 95% CI.
Postpartum mothers who were married (living with their sexual partner) were four times more knowledgeable about the LAM compared with those who were not living with their sexual partner (AOR = 4.0; 95% CI: 1.83–9.0). Mothers who had attended school were nearly twice as likely to be knowledgeable about LAM as those who had never attended school (AOR = 1.8; 95% CI: 1.16–2.76). Postpartum mothers aged 18–30 years were less knowledgeable about LAM than mothers aged 31–49 years (AOR = 0.42; 95% CI: 0.28–0.63). Participants who practiced exclusive breastfeeding were more knowledgeable about LAM than those who practiced mixed feeding or did not breastfeed (AOR = 1.61; 95% CI: 1.10–2.35). Finally, mothers who attended higher-level hospitals were more knowledgeable about LAM than those who attended lower-level hospitals (AOR = 1.5; 95% CI: 1.02–2.17) (Table 6).
Table 6.
Bivariable and multivariable logistic regression analysis of postpartum mothers’ knowledge of the lactational amenorrhea method in Northeast Ethiopia (n = 607)
| Variables | Maternal knowledge of LAM | COR, P-value | AOR (95%CI) | P-value | |
|---|---|---|---|---|---|
| Poor n(%) |
Good n(%) |
||||
| Marital status | 0.001* | ||||
| Married | 241(42.1) | 332(57.9) | 1.62, 0.09 | 4.06(1.83, 9.02) | |
| Not living with sexual partner | 24(70.6) | 10(29.4) | 1 | 1 | |
| Ever attended school | 0.008* | ||||
| Yes | 199(41.4) | 282(58.6) | 1.55, 0.02 | 1.79(1.16, 2.76) | |
| No | 66(52.4) | 60(47.6) | 1 | 1 | |
| Breast feeding practice | 0.014* | ||||
| Breastfeeding (BF) only | 168(40.5) | 247(59.5) | 1.5, 0.02 | 1.61(1.10, 2.35) | |
| Mixed feed or not BF | 97(50.5) | 95(49.5) | 1 | 1 | |
| Health facility type | 0.038* | ||||
| Referral hospitals | 160(40) | 240(60) | 1.54, 0.01 | 1.49(1.02, 2.17) | |
| District hospitals | 105(50.7) | 102(49.3) | 1 | 1 | |
| Age (in years) | 0.000* | ||||
| 18–30 | 209(48.2) | 225(51.8) | 0.51, 0.00 | 0.42(0.21, 0.63) | |
| 31–49 | 56(32.4) | 117(67.6) | 1 | 1 | |
| Counseling services | 0.07 | ||||
| No | 149(40.7) | 217(59.3) | 1.35,0.07 | 1.36(0.96–1.91) | |
| Yes | 116(48.1) | 125(51.9) | 1 | 1 | |
*Indicates statistically significant factors at p-value of < 0.05
Maternal knowledge of LAM as a predictor of exclusive breastfeeding practice
In this study, the Chi-square test result showed a statistically significant association between maternal knowledge of the lactational amenorrhea method and exclusive breastfeeding practices among postpartum mothers (χ² = 5.378, p = 0.02). Moreover, the linear-by-linear association was significant (χ² = 5.369, p = 0.02), suggesting a trend in which higher maternal knowledge of LAM is associated with greater practice of exclusive breastfeeding. Overall, mothers with good knowledge of LAM were more likely to practice exclusive breastfeeding compared with those who had limited knowledge (Table 7).
Table 7.
Statistical association between exclusive breastfeeding practice and maternal Knowledge of lactational amenorrhea method in northeast Ethiopia (n = 607)
| Maternal knowledge of LAM | Exclusive breastfeeding practice | |
|---|---|---|
| Good n (%) |
Poor n (%) |
|
| Knowledgeable | 168 (63.4) | 97 (36.6) |
| Not knowledgeable | 247 (72.2) | 95 (27.8) |
| Chi-square test: (χ² = 5.378, p = 0.02*) | ||
*Shows statistically significant
Discussion
In this study, the prevalence of good exclusive breastfeeding practice among postpartum mothers was 415 (68.4%), which is consistent with a study conducted in Mekele, Ethiopia, where the prevalence was 64.4% [21]. Similarly, the proportion of mothers with good knowledge of the lactational amenorrhea method was 342 (56%).
This study finding on exclusive breastfeeding practice was higher than that reported in other studies done in Nigeria (31%) [13], Chamo town (26.8%) [14], South Africa (39%) [9], and Mizan Aman town (26.4%) [15], where participants exclusively breastfed their children for six months.
The observed differences may be attributed to variations in the study period, study design, and sociodemographic characteristics. Most of the previous studies were conducted more than five years ago and had smaller sample sizes (e.g., the Nigerian study had a sample size of 179, which may increase the margin of error), whereas this study utilized relatively larger sample. Another possible explanation is that data were collected via interviewer-administered surveys, which may have led participants to over-report exclusive breastfeeding practices.
Exclusive breastfeeding practice in this study was lower than the prevalence reported in a systematic review and meta-analysis in Africa (55.9%) [8]. In Mecha District, 92.1% of participants had good knowledge of exclusive breastfeeding, but only 38.5% actually practiced it [16]. The observed differences may be due to variations in sociodemographic characteristics; for example, participants in Mecha district were employed women, unlike those in this study. Additionally, systematic review and meta-analysis findings reflect pooled estimates that may accommodate outlier results from different countries.
Sensitivity analysis was also performed using a mixed-effects logistic regression model, which included hospital as a random effect. The results were consistent with the primary analysis and showed no meaningful changes in effect estimates or statistical significance. This consistency may be explained by the similarity of maternal and child health services (such as postnatal care, child immunization, and other MCH services) across all hospital levels and the comparable sociodemographic characteristics of the study participants.
The factors significantly associated with exclusive breastfeeding practice were marital status, educational level, and reason for hospital visit.
Postpartum mothers who lived with a sexual partner (married) were less likely to practice exclusive breastfeeding compared with those who did not live with their sexual partner. This finding indicates a relatively higher prevalence of exclusive breastfeeding among non-married women. The underlying reasons for this observation are not fully understood, but it may be speculated that factors such as economic status, maternal employment, and workload play a role, even though these variables were not measured in this study.
Postpartum mothers with formal education (grade one and above) were twice as likely to practice exclusive breastfeeding compared with those without formal education. This aligns with evidence that maternal education enhances healthcare utilization, as educated mothers are better able to weigh the benefits and challenges of breastfeeding and follow healthcare providers’ counseling, including understanding LAM criteria. Similar findings have been reported in other study [14].
Interestingly, postpartum mothers who visited health facilities for maternal health services were less likely to practice exclusive breastfeeding compared with those who attended for family planning. This finding is novel, as previous studies have not explored this association. It highlights potential gaps in maternal and child health counseling, suggesting that the benefits of exclusive breastfeeding may not be adequately emphasized during maternal health service visits. Most mothers, however, visit health facilities primarily for child immunization, either for the oral polio vaccine within two weeks after birth or to start the regular immunization schedule at six weeks. In many health facilities, for various reasons, immunization and family planning services are provided in the same room, allowing mothers to receive counseling on postpartum family planning and exclusive breastfeeding, including information on LAM.
The level of maternal knowledge of LAM among postpartum women attending hospitals in this study was 56%, which is consistent with a study done in Indonesia (59.6%) [22], but lower than that reported in Egypt (65.3%) [23]. These differences may reflect variations in study design, socioeconomic status, and sample size across the studies. Conversely, the prevalence of good maternal knowledge of LAM in this study was higher than that reported in a study conducted in Turkey (28.6%) [24], Uganda (< 1%) [25], and Pakistan, where 80% of women had no information about LAM [19]. These discrepancies may be attributed to differences in sample size (smaller in Pakistan), study design, study population differences (e.g., the Ugandan study included only adolescent mothers), measurement tools, and time of research (older studies).
The prevalence of maternal knowledge of lactational amenorrhea method observed in this study (55%) was considerably higher than the estimate used for sample size calculation (8.8%) in Tigray region, Ethiopia. This difference may be attributed to variations in study population, setting, or temporal changes, study period.
Factors associated with maternal knowledge of LAM were age, marital status, education status, hospital level, and exclusive breastfeeding practice.
Married postpartum mothers were four times more knowledgeable about LAM compared with unmarried mothers. This may reflect the support provided by male partners in accessing maternal and child health services, enabling mothers to confidently discuss family planning options and meet LAM criteria, which require male partner cooperation.
Participants who attended formal education were twice as knowledgeable about LAM as those who did not attend formal education (AOR = 1.8; 95% CI: 1.16–2.76). Education improves awareness and comprehension during counseling, enable mothers to implement LAM effectively and understand its benefits for both the child and themselves [19].
Postpartum mothers aged 18–30 years were less knowledgeable about LAM compared with those aged 31–49 years (AOR = 0.42; 95% CI: 0.28–0.63). Younger mothers may lack prior childbirth experience and might have had limited opportunity for LAM counseling.
Postpartum mothers who attended higher-level hospitals were more knowledgeable about LAM compared with those who visited lower-level facilities (AOR = 1.5; 95% CI: 1.02–2.17). This is a new finding and may be explained by the availability of well-trained and experienced healthcare professionals at higher-level hospitals. These professionals are more likely to provide comprehensive counseling and practical guidance on LAM, helping mothers understand and correctly apply its criteria, which require careful and precise implementation. In contrast, lower-level facilities may have fewer trained staff and limited resources, potentially reducing opportunities for effective LAM counseling.
Overall, postpartum mothers with good knowledge of the lactational amenorrhea method were more likely to practice exclusive breastfeeding. This aligns with expectations, as understanding the three LAM criteria reinforces adherence to exclusive breastfeeding. Reverse causation is possible in cross-sectional studies, as exclusive breastfeeding practice could also enhance maternal knowledge of LAM. This study, however, examined only the association between LAM knowledge and exclusive breastfeeding practice, not causation.
Strengths of the study
Previous studies did not simultaneously examine both exclusive breastfeeding practices and maternal knowledge of the lactational amenorrhea method, and were often limited to specific types or levels of health facilities. In contrast, the present study included participants from different levels of hospitals, allowing for a more comprehensive assessment of these factors across varied healthcare settings.
Limitations
This study has several limitations. The facility-based cross-sectional design prevents causal inferences. The generalizability of the findings limited to all postpartum women, and does not allow determination of the direction of observed associations. Security challenges in northern Ethiopia hindered the feasibility of conducting a community-based study. One limitation of this study is that the findings were not triangulated with qualitative data. Moreover, recall and social desirability biases may have influenced the reported rates of breastfeeding practice, as data were collected via interviewer-administered questionnaires, potentially leading participants to overreport their practices. To minimize these biases, female data collectors were employed, participants were approached in a friendly manner, and the purpose of the study was clearly explained before data collection.
Conclusions
In this study, 68.4% of postpartum women practiced exclusive breastfeeding, while 56% had good knowledge of the lactational amenorrhea method, both of which are low as compared with rates stated in other countries. The factors significantly associated with exclusive breastfeeding were marital status, educational level, and reason of hospital visit. Marital status, educational status, hospital level and exclusive breastfeeding practice were significantly associated with maternal knowledge of lactational amenorrhea method as natural contraceptive method.
Recommendation
To improve exclusive breastfeeding practices and maternal knowledge of LAM, structured postnatal education should be strengthened across all hospitals. Postnatal care units, immunization clinics, and referral hospitals should prioritize targeted counseling on LAM and exclusive breastfeeding, highlighting the benefits for both mother and child. Referral hospitals could implement dedicated postnatal education sessions, while general hospitals may integrate brief counseling into routine postnatal visits. Future research should use adequately powered, community-based, mixed-methods study designs that consider socioeconomic, cultural, and psychological barriers to exclusive breastfeeding. Such studies would provide a more comprehensive understanding of the factors influencing maternal practices and inform more effective interventions.
Acknowledgements
We would like to express our heartfelt gratitude to all the data collectors and study participants. Last but not least, we thank all hospital staff for providing the necessary materials and their cooperation in this study.
Abbreviations
- AOR
Adjusted Odds Ratio
- CI
Confidence interval
- COR
Crude odds ratio
- DHS
Demographic health survey
- EBF
Exclusive breast feeding
- EPI
Expanded program of immunization
- HIV
Human immune deficiency virus
- PMTCT
Prevention of mother to child transmission
- PNC
Post natal care
- LAM
Lactational amenorrhea method
- MCH
Maternal and child health
- SRS
Simple random sampling
- USA
United states of America
Author contributions
DTZ, MAA and GTD participated in all phase of the study process from the conception of this research until final manuscript approval for publication.
Funding
This study was funded by Jimma University. The funder has no role in the conceptualization, design, data collection, analysis, or preparation of the manuscript.
Data availability
The data supporting the conclusions of this article is included within the article.
Declarations
Ethics approval and consent to participate
Ethical approval for this study was obtained from the Institutional Review Board (IRB) of Jimma University Institute of Health and Wollo University college of medicine and health sciences, school of nursing and midwifery ethical review committee (Ref. No: SNM/355/22). Informed written consent was obtained from each participant prior to data collection. Participants were informed about the purpose of the study and had the full right to refuse participation. All information provided by participants was kept confidential. Participants under the age of 18 were not included in the study. The study was conducted in accordance with the principles of the Declaration of Helsinki.
Consent for publication
Not applicable.
Competing interests
The authors declare no competing interests.
Footnotes
Publisher’s note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
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Associated Data
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Data Availability Statement
The data supporting the conclusions of this article is included within the article.