Knowledge and practices of exclusive breastfeeding among mothers in rural areas of Rajshahi district in Bangladesh: A community clinic based study

Md Masud Rana; Md Rafiqul Islam; Md Reazul Karim; Ahmed Zohirul Islam; Md Akramul Haque; Md Shahiduzzaman; Md Golam Hossain

doi:10.1371/journal.pone.0232027

. 2020 May 8;15(5):e0232027. doi: 10.1371/journal.pone.0232027

Knowledge and practices of exclusive breastfeeding among mothers in rural areas of Rajshahi district in Bangladesh: A community clinic based study

Md Masud Rana ¹, Md Rafiqul Islam ^1,^*, Md Reazul Karim ¹, Ahmed Zohirul Islam ¹, Md Akramul Haque ², Md Shahiduzzaman ³, Md Golam Hossain ⁴

Editor: Russell Kabir⁵

PMCID: PMC7209213 PMID: 32384096

Abstract

Background

World Health Organization (WHO) suggests that exclusive breastfeeding (EBF) is the best nutrition for the neonate. Still, it remains a big challenge to establish EBF not only in Bangladesh but also in any developing countries.

Objective

The aim of this study was to determine the level of knowledge and practices on EBF and its relationship between different socioeconomic and demographic factors among mothers having at least one child of aged 6–12 months in the rural area of Rajshahi District, Bangladesh.

Methodology

A community clinic (CC) based study has been conducted by using semi-structured questionnaire. A total of 513 mothers having at least one child aged 6–12 months from 32 different CC in the rural area of Rajshahi District, Bangladesh during September to December 2015. A composite index, chi-square test, and logistic regression model were utilized in this study.

Results

The prevalence of knowledge and practices on EBF were 34.5% and 27.9% among mothers having at least one child aged 6–12 months. From the analyses, mothers age of ≥21 years were (adjusted odds ratio (AOR) = 13.840, 95% CI: 7.394–25.904; p<0.001) times more likely to have knowledge on EBF and (AOR = 0.084, 95% CI: 0.050–0.143; p<0.05) times less likely to have practices of EBF compared to mother’s age ≤20 years. Service holders mothers were (AOR = 9.992, 95% CI: 4.485–22.260, p<0.05) times more likely to have practices than that of house wife. Home delivery mothers was (AOR = 0.208, 95% CI: 0.111–0.389; p<0.05) times less likely to have practices of EBF than that of the hospital delivery mothers. Those mothers monthly family income ≥10,000 Bangladeshi taka (BDT) currency was (AOR = 0.092, 95% CI: 0.050–0.168, p<0.05) times less likely to have practices of EBF compared to their counterparts.

Conclusions

This study was found poor knowledge and practices on EBF. This study suggested that education and EBF related intervention could play an important role to increase good knowledge and practices on EBF among mothers. Malnutrition will be decreased if EBF was widely established in Bangladesh.

Introduction

Durable evidence specifies that exclusive breastfeeding (EBF) is one of the best nutrition practices for children health, growth and nutrition and termed as an optimal strategy for feeding newborn and young infants [1–5]. According to WHO and UNICEF, EBF should start within less than one hour of delivery and must have to continue up to 6 months of infant’s age as it is the only source diets or fluids for babies at that age and have to sustain with balancing feeding on at the minimum 24 months of infants age [6]. Malnutrition in all its forms, either indirectly or directly, is responsible for about half of the all deaths including infants worldwide [7]. Children especially new born babies are at large danger of malnutrition from first six months of life when breast milk alone is necessary to meet all nutritious supplies and balancing feeding needs to be in progress [8, 9]. Good practice of EBF can prevent 13.8% of all deaths among infants aged less 2 years and 11.6% of under 5-years children deaths [10–12] but unfortunately a report estimated in 2012 that, only 35% of infants were exclusively breastfed globally [13]. EBF, by its various recognized health welfare for babies, children, and their mothers, was a crucial plan to recover public health [14]. Low breastfeeding rates were found in Canada, and especially in industrialized countries [15]. Besides, EBF at least 6 month’s was not a general practices in advanced nations, and it was still fewer in developing nations [16]. The key gap was sympathetic to the physical, organic, cultural and socio economic factors of the length of EBF. In this review, nutrient capability of EBF is maximum usually assessed for infant development [17]. In the South East Asia, it was reported that prevalence of EBF were 55.0%, 66.1%, 51.4%, 70.0% for India, Nepal, Bhutan, Sri Lanka respectively [18–21].

In global health congress, EBF increased to ensuing first six months [22–24]. Nearly Bangladeshi children are breastfed to an approximate extent to the initial year of life and luckily, the continuance of breastfeeding is up to the second year of baby’s life, through 91% ongoing to breastfeed [25]. Bangladesh has a key amounts of malnourishment in South East Asia with nearly partial for children aged 59 months being underweight and 64%, 36%, 35.90% EBF reported [23,24,26,27]. To determine the poor newborn nourishing knowledge, practices and it doubles of the exact aims of the state plan for baby and early born children feeding [28].

Several studies have been performed to assess the knowledge, perception and practices on breastfeeding among females and shown global trends in EBF [13, 28], knowledge, attitude and techniques of breastfeeding under five children mothers in Nigerian [29,30], knowledge and practices of EBF in Nigerian populations [28]. Special concern has been paid to the association between school going girl’s perception and knowledge about breastfeeding [31], knowledge, and practice of baby’s moms towards EBF and its related issues in Ethiopia [32–34]. Though only a few studies have been carried out in this regard, most of these studies were carried out in developed country settings [35–36]. Furthermore, concerning issued the measurement of knowledge and practices about EBF have not been adequately addressed in earlier studies. The difficulty of judging knowledge lies in its multidimensional aspects. Most of the studies have been focused on a few indicators. In Bangladesh most of the rural village covered by the community clinic so, this study measured by composite index. Therefore, the aim of this study was to assess the knowledge and practices on EBF among mothers who having at least one child aged 6–12 months in Rajshahi District, Bangladesh.

Methods

Design and study population

A community clinic based study was conducted in the rural area of Rajshahi district, Bangladesh. There are several reasons why we select the mothers having at least one child aged 6–12 months from different CCs in Rajshahi district. This area is situated at the nearest of Rajshahi is identified as divisional and education city [37]. Most of the subjects were living at the different catchment area of CCs in Paba upazila (sub-district) Rajshahi district, Bangladesh.

Simple size determination

Since study population is well-known mothers having at least one child age 6–12 months, the following formula has been used for collecting sample size: n = N/ (1+Nd²), where n = required sample size, N = population size (5,123), d = marginal error (0.05). The formula provided that the minimum sample size was estimated to be 366 for this study. But, for better results, we have collected data from 513 respondents [38].

Before sampling, 6–12 month children lists were got from the Paba upazila Health Complex, Rajshahi that list used for expanded programme on immunization. A two-stage purposive sampling approach was accepted to choose the mothers having at least one child age 6–12 months from Rajshahi district. In the first stage, out of nine upazila of Rajshahi district, purposively selected one upazila named Paba. In the second stage, purposive sampling technique was used to select sample size. There were 232 CCs in Rajshahi district and 32 CCs in Paba upazala. In Paba upazila, CCs catchment area, 5123 mothers were living who were taken different types of general, maternal, child health, family planning and expended program on immunization (EPI) services from CCs. In Paba, 530 mothers were selected out of 5,123, mothers who having at least one child age 6–12 months and finally 513 samples were successfully interviewed [39].

Data collection

In this study, data were collected from September to December‘2015 (i) socio-demographic characteristics and (ii) knowledge about EBF using a semi-structured questionnaire. The questionnaire was reviewed by five specialists and assistants, and initially piloted to validate the questionnaire. The questionnaire also modified based on piloted results of the pre-test exercise to make it easier to realize and for response. Five fully trained and experienced enumerators conducted the interview.

Outcomes variables

The dependent variable in this study is the level of knowledge about EBF, which was measured through nine different questions, namely: i) What do you mean by EBF? ii) Do you know when EBF should be started? iii) Do you know when supplementary feeding is needed? iv) Do you know water should allow in EBF period? v) Do you know honey should allow in EBF period? vi) Do you know what the appropriate duration of EBF is? vii) Do you know what the benefits of EBF? viii) Do you know what is happen if EBF were not done? ix) Do you know any additional feed is essential during EBF period?

Another outcome variable in this study was practices about EBF, which was measured through two different questions, namely: i) Do you feed any complement food for your last baby during EBF? ii) What type of feed you allow during your EBF period for your last baby? The respondent’s knowledge and practice were scored used a system adopted from earlier studies. The individually appropriate reply was given 1 point, while improper replies received 0 point [40].

Independent variables

In this study, socio-economic and demographic factors were included as independent variables. Age classified into two groups: a group (≤ 20 years), and other age groups (≥ 21years). Place of delivery was divided into two group hospital and home and occupation also classified into two categorized such as housewife and service holder. Education was classified based on the formal learning system in Bangladesh: Illiterate (0 years), primary education (1–5 years), secondary and higher (6 years or more). Type of family was categorized as per joint or single family. Respondents monthly income was categorized as ≤9,999 Bangladeshi taka (BDT) currency or ≥10,000 Bangladeshi taka (BDT) currency considered as yes or no.

Statistical analyses

Statistical Package for Social Science (SPSS) version 22 IBM was used for analyzing the data. Descriptive analyses were conducted to ascertain the socio-economic and demographic factors by knowledge and practices of EBF of the subjects. Socio-economic and demographic differences regarding knowledge and practices of EBF were assessed by χ² test through significance for all analyses was set at p<0.05. The study designed was completely adjusted models to analyze each binary outcome variables. This research entered all the variables instantaneously into the binary logistic regression models. The adjusted odds ratio (AOR) was observed to assess the strength of the association’s at 95% CI for significance test.

The knowledge index was created through the sums of binary input variables, where the highest and lowest values were selected for each underlying pointer. The enactment of individually pointer was articulated using a unit-free index between 0 and 1 in accordance with the structure technique of the Human Development Index [41].

Knowledge index = (Actual value- Minimum value) / (Maximum value-Minimum value)

The scores was created then categorized as the groups labeled as poor and good knowledge and practices [41, 42]. Before measuring the level of knowledge and practices using consistent or reliability of respondents answer. The knowledge score is poor = 0–4 and good = 5–9 and the practice level score is poor = 0 <1, good = ≥1 [42].

Ethics approval and consent to participate

CCs based activities implemented by Development Association for Self-reliance Communication and Health (DASCOH Foundation) and financially supported by Swiss Red Cross (SRC). DASCOH Foundation was got approval from Community Based Health Care (CBHC) under the Ministry of Health and Family Welfare Government of Bangladesh. Ethics committee of Non-governmental Affairs Bureau (NGOAB) of Bangladesh has approved this project. Before going to data collection this study were shortly discussed with the participants about its objectives. For this study researchers were received written consent from all of the subjects.

Results

In the study, it was surveyed that the knowledge and practices on EBF among mothers. Table 1 showed the socio-economic and demographic factors about knowledge on EBF related appearances of the respondents. A total of 513 individuals were involved in this study. From the total sample population, approximately 61.2% and 79.5% were ≤ 20 years of age and Muslim. Out of 513 simple, 79.5% of respondents came from joint family. Furthermore, it was found that these characteristics were statistically significant (p<0.05). 34.5% respondents had a good knowledge on EBF and here delivery place, education and monthly family income were statistically insignificant with knowledge level.

Table 1. Socio-demographic characteristics according to knowledge on EBF.

Characteristics	Knowledge about EBF
	N (%)	Good	Poor	p-value
	N (%)	177 (34.5%)	336 (65.5%)	p-value
Age in years				0.001
≤20 years	314(61.2)	164 (52.2)	150(47.8)
≥21 years	199(38.8)	13(5.5)	186(93.5)
Religion				0.001
Muslim	408(79.5)	115(28.2)	293(71.8)
Non-Muslim	105(20.5)	62(59.0)	43(41.0)
Delivery place				0.112
Hospital	309(60.2)	115(37.2)	194(62.8)
Home	204(39.8)	62(30.4)	142(69.6)
Occupation				0.370
Housewife	308(60.0)	111(36.0)	197(64.0)
Service holder	205(40.0)	66(32.2)	139(67.8)
Educational status				0.108
Illiterate	141(27.5)	56(39.7)	85(60.3)
Primary	98(19.1)	26(26.5)	72(73.5)
Secondary & Higher	274(53.4)	95(34.7)	179(65.3)
Type of family				0.001
Joint	408(79.5)	115(28.2)	293(71.8)
Single	105(20.5)	62(59.0)	43(41.0)
Monthly family income in BDT				0.126
≤9,999	307(59.8)	114(37.1)	193(62.9)
≥10,000	206(40.2)	63(30.6)	143(69.4)

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Table 2 showed the socio-economic and demographic factors about practices on EBF related appearances of the respondents. A total of 513 individuals were involved in this stud. From the total sample population, 61.2% and 78.9% were ≤ 20 years of age and Muslim group respectively. Out of 513 simple, 60.2% of deliveries were at hospital and 61.4% respondents were housewife. In case of education, 27.5% respondents were illiterate, 19.1% were primary educated and the remaining 53.4% had secondary or higher level of education and 79.5% of respondents came from joint family. A major portion of respondent’s (59.8%) monthly family income was below 9,999 BDT. From the total sample population, 27.9% respondents have practice on EBF. Furthermore, it was found that these characteristics were statistically significant (p<0.05).

Table 2. Socio-demographic characteristics according to EBF practices.

Characteristics	Practices on EBF
	N (%)	Good	Poor	p-value
	N (%)	143(27.9%)	370(72.1%)	p-value
Age in years				0.001
≤20 years	314(61.2)	122(38.9)	192(61.1)
≥21 years	199(38.8)	21(10.6)	178(89.4)
Religion				0.001
Muslim	405(78.9)	143(35.3)	265(64.7)
Non-Muslim	108(21.1)	0(0),	108(100.0)
Delivery place				0.001
Hospital	309(60.2)	130(42.1)	179(57.9)
Home	204(39.8)	13(6.4)	191(93.6)
Occupation				0.001
Housewife	315(61.4)	136(43.2)	179(56.8)
Service holder	198(38.6)	07(3.5)	191(96.5)
Educational status				0.006
Illiterate	141(27.5)	89(63.1)	52(36.9)
Primary	98(19.1)	80(81.6)	18(18.4)
Secondary & Higher	274(53.4)	201(73.4)	73(26.6)
Type of family				0.001
Joint	408(79.5)	143(35.1)	265(64.9)
Single	105(20.5)	0(0)	105(100.0)
Monthly family income in BDT				0.001
<9,999	307(59.8)	130(42.1)	177(57.7)
≥10,000	206(40.2)	13(6.3)	193(93.7)

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It was found that the model chi-square was 134.104 (p-value = 0.001) and Nagelkerke R² of the fitted model was 0.318 which expressed the good fit of the model that were shown at the bottom of Table 3. Regression analysis of the factors associated with the knowledge and among mothers on EBF. Children mothers age ≥21 years (adjusted odds ratio, (AOR) = 13.840; 95% confidence interval CI: 7.394–25.904), mothers were more likely to have a good knowledge on EBF compared to their counterparts and it was statistically significant (p<0.05).

Table 3. Effects of socio-economic and demographic factors for knowledge on EBF.

Characteristic	p-value	Adjusted odds ratio (AOR)	95% CI
Characteristic	p-value	Adjusted odds ratio (AOR)	Lower	Upper
Age in years
≤20 years ^R
≥21 years	0.001	13.840	7.394	25.904
Religion
Muslim ^R
Non-Muslim	0.358	4.607	0.177	119.916
Type of family
Joint ^R
Single	0.510	3.004	0.114	79.057

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Model summary:

Model chi-square = 134.104 (p-value = 0.001), Nagelkerke R² of the fitted model = 0.318.

In Table 4, model summary of the level of practices on EBF was also demonstrated at the bottom of this table. It was found that the model chi-square was 388.475 (p value = 0.001) and Nagelkerke R² of the fitted model was 0.765 which also express the good fit of the model. The respondents aged ≥ 21years (AOR = 0.084; 95% CI: 0.050–0.143), home (AOR = 0.208; 95% CI: 0.111–0.389), ≥ 10,000 BDT monthly family income (AOR = 0.092; 95% CI: 0.050–0.168) children mothers were less likely to have practices on EBF compared to their counterparts and these factors were statistically significant (p<0.05). Moreover, service holder (AOR = 9.992; 95% CI: 4.485–22.260) mothers were more likely to have good practices on EBF than their counterparts and it was statistically significant (p<0.05).

Table 4. Effects of socio-economic and demographic factors for practices on EBF.

	p-value	AOR	95% C.I
	p-value	AOR	Lower	Upper
Age in years
≤20 years ^R
≥21 years	0.001	0.084	0.050	0.143
Religion
Muslim ^R
Non-Muslim	0.057	0.061	0.003	1.092
Delivery place
Hospital ^R
Home	0.001	0.208	0.111	0.389
Occupation
Housewife ^R
Service holder	0.001	9.992	4.485	22.260
Educational status
Illiterate ^R
Primary	0.752	1.192	0.401	3.547
Secondary & Higher	0.419	1.435	0.597	3.452
Type of family
Joint ^R
Single	0.518	2.500	0.155	40.304
Monthly family income in BDT
≤9,999 ^R
≥10,000	0.001	0.092	0.050	0.168

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Model summary:

Model chi-square = 388.475 (p-value = 0.001) and Nagelkerke R² of the fitted model = 0.765.

Discussion

This study surveyed the knowledge and practices on EBF among mothers at rural area of the CCs in Rajshahi district, Bangladesh. It were observed that prevalence of EBF were Eastern and Southern Africa 55%, South Asia 54%, Latin America and the Caribbean 38%, North America 35%,West and Central Africa 34%, Eastern Europe and Central Asia 33%, East Asia and Pacific 30%, Middle East and North Africa 30% and Globally 42% [26]. This study assumed that, as the area was situated at very near of divisional and educational city and that most of the mothers living in these area of CCs, maximum respondents were knowledgeable and practicable on EBF, but this study demonstrated that a few percent of mothers in this area have knowledgeable and practicable on EBF. In Bangladesh similar study were found in practice level on EBF [43, 44]. The study found that, younger respondents’ ≤ 20 years had knowledge and practices as likened to the older respondents’ ≥ 21 years similar results were found in others countries [45]. It was found that hospital delivery respondents had practices as associated to their counterparts. Study results was consistent with previous other study in Ethiopia [46, 47]. An extra assumption was that most of the house wife mother, secondary and higher level of educated mothers knew EBF benefit so their practices level is high as paralleled with the housewife respondents. We found that housewife respondents have practices as matched to their counterpart. A picture of rural area housewife respondents watched Bangladesh television. This study result is consistent with previous other studies [48, 49]. This study was assumption that educated mothers have and practices. Joint family member’s mothers have knowledge and practices were different as compared to the single family mothers. This study observed that Joint family member’s mothers in our study share their findings with other family members but not properly follow various types of religious orthodoxy. Though, study highlights the need for EBF health education program educations children mothers. It was found that ≤ 9,999 BDT income respondents have practice as compared to their counterparts. Similar results were found in previous other studies [50, 51]. An extra assumption that most of the low monthly income mother watched BTV and follow those indications as compared with the rich housewife mothers they watch different type of Indian serial through dish channel [49].

There are major two findings. First, study have found very poor knowledge and practices 34.50%, 27.9% on EBF was noted among study participants. Second, mothers have knowledge and practice about EBF who were aged ≤ 20 years, Housewife, hospital delivery, joint family members and ≤ 9,999 BDT monthly family income mothers were more likely to have knowledge and practices on EBF.

As a final point, the idea of knowledge and practices on EBF, which has some definitions; so, it is challenging to measure, particularly using the questionnaire. However, this study measures the knowledge and practices through a lot of indicators which were reflected by several previous studies [26,52–55].

This study had some limitations such as it was a community clinic based study so, it did not permit us to create any complete progressive associations for identifying knowledge and practices on EBF and several socio-economic and demographic factors and health performance linked with this features. This study suggested for more longitudinal research to realize this complex relationship and understand the fundamental tools. Secondly, there are 64 districts and 491 sub-districts (upazilas) in Bangladesh, in this study, considered only one district and one upazila of considering district.

Conclusions

This study found poor knowledge and practices on EBF among mothers. Binary logistic regression model demonstrate that a few number of factors were influencing EBF knowledge and practices. Female education should be increased substantially and hence more job opportunities could be created in various dimensional job sectors for them. This study also suggested that social safety net program could play an important role to increase knowledge and practices on EBF among mothers. Malnutrition will be decreased if EBF was widely established. This study provides important information to improving knowledge and practices on EBF in removing malnutrition from Bangladesh.

Supporting information

S1 File

(SAV)

Click here for additional data file.^{(19.7KB, sav)}

Acknowledgments

The authors gratefully acknowledge the authority of CCs of Rajshahi District, Bangladesh for giving permission to take data from CCs catchment area. We also acknowledge Md. Ektier Uddin, DASCOH Foundation and Swiss Red Cross to help for data collection from CCs.

Data Availability

All relevant data are within the manuscript and Supporting Information files.

Funding Statement

The author(s) received no specific funding for this work.

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PLoS One. doi: 10.1371/journal.pone.0232027.r001

Decision Letter 0

Russell Kabir

19 Dec 2019

PONE-D-19-28733

Knowledge and practice of exclusive breastfeeding among mothers in rural areas of Rajshahi district in Bangladesh: A community clinic based study

PLOS ONE

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Reviewer #1: Partly

Reviewer #2: Yes

**********

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Reviewer #1: Yes

Reviewer #2: Yes

**********

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Reviewer #1: Yes

Reviewer #2: Yes

**********

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Reviewer #2: Yes

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Reviewer #1: Comments to the Author

In this manuscript, the authors investigate the knowledge and practices on exclusive breastfeeding (EBF) and its relationship between different socioeconomic and demographic factors among mothers having at least one child (6-12 months age) in a rural area of Rajshahi District, Bangladesh. This study community clinic study with semi-structured questionnaires with sample size of 513 mothers. This study reports poor knowledge and practices on EBF, education, and EBF related intervention have an essential role in increasing knowledge and practices on EBF. Moreover, authors suggested malnutrition may be decreased if EBF was established in Bangladesh.

However, there are some suggestions and major concerns that must be addressed.

1. BMC Pediatr. 2018; 18: 93 (PMID: 29499670) Previous publication from the same group with similar kind of study (a country based cross-sectional study including Rajshahi) and its outcome similar; What is the novelty in this study? In what means this study “best of my knowledge none study has not been conducted on EBF” Line 108 statement?

2. Whether data used in the present study was extracted from the large scale of data-set collected by Bangladesh Demographic and Health Survey (BDHS) -2014? Although, Data collection period mentioned September to December 2015, is that part of BDHS? For clarification explanation must be included.

3. Line: 196 “Monthly family income was below 9,999 BDT” What was the average monthly family income to predict the socioeconomic status of well-being as per statistic; references must be included.

4. Abbreviate at first instance, check throughout the manuscript. Example: adjusted odds ratio (AOR), Bangladeshi taka (BDT) currency (check-in abstract also).

5. Avoid repeated discussion/results and check for those portions.

6. Fewer graphical representations of relevant data (key study outcome) would be interesting along with table.

7. It is interesting to compare previously published studies, for example, “Prevalence of exclusive breastfeeding and associated factors among mothers in rural Bangladesh: a cross-sectional study” Int Breastfeed J 9, 7 (2014) DOI:10.1186/1746-4358-9-7.

8. There are many other minor errors of syntax and grammar throughout the text, which need to be fixed.

Reviewer #2: 1. The introduction section need more clarity esspecially the studies of Banglash need to be reffered for contexual understanding of the issues. Further, the studies of south east aia can be highlighted to understand the standng of breat feeding of bangladesh with the regional practices.

2. the methodology seems to not explained proporly sothat the tudy can be dulpicated elsewhere involveig the methods . As of now the methodology is scant and processes need to be explained.

3. The important finding sneed to be highlighted. there are many commion and generalizaed indings those need to be edit out to make the article crispy and easy to understand.

4. The disscussion section needs a lot of effort to bring the global perspective in the study and need high level of comparision. the factors like religion social groups and the practice of breast feeding need to be ompared.

5. the conclusion must be from the finding like breast feeding and the factors relating to practices of bangladesh. Make it strong.

**********

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Reviewer #1: No

Reviewer #2: Yes: Ranjit Kumar Dehury

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PLoS One. 2020 May 8;15(5):e0232027. doi: 10.1371/journal.pone.0232027.r002

Author response to Decision Letter 0

31 Mar 2020

Point wise response to academic editor comments:

1. I ensure that our manuscript meets PLOS ONE‘s style.

2. We uploaded questionnaire of

i) Original/Mother’s language.

ii) English language as supporting information.

3. The authors declare that they have no competing interest.

DASCOH Foundation is nonprofit organization and they have no any fund for publication and its supporting document is provided

4. Figure 1 is omitted from the manuscript

5. SPSS data file is uploaded in Data Availability statement

6. We have already ensured the affiliation of each author

7. It is already deleted

8. Table 3 is inserted in the respective section in the text of the manuscript (in the line of 206 in Manuscript file)

# 1. Reviewer comments:

1. BMC Pediatric. 2018; 18:93 is already studied. Some variable are same and some are different but the outcome variable is converted into composite index, then it is classified into two groups as good and poor.

“Dependent variable is converted to composite index”- This study worked on EBF in Rajshahi district as well as community clinic based study. Most of the researchers studied on EBF practices but this study worked about knowledge and practices on EBF. One of the novelty of this study was to introduce the composite index on EBF. “To the best of our knowledge none study has been conducted on EBF” this section is deleted from the manuscript

2. Actually the data of this study is primary collected during the period of September to December 2015. Consequently this data are not extracted from Bangladesh Demographic and Health Survey (BDHS) 2014. In fact, this study is not part of BDHS 2014.

3. According to World Bank national accounts data, and OECD National Accounts data files’2015 per capital income in Bangladesh 1,248.453 US dollar its exchange rate for December 31, 2015, 1 US dollar = 78.9031 BDT. For this reason we divided monthly family income into two categories such as ≤ 9,999 BDT and ≥ 10,000 BDT.

4. Adjusted odds ratio (AOR) and Bangladeshi taka (BDT) is corrected in the abstract as well as in the respective sections (in the line 43 and 49 of Manuscript).

5. We carefully check and revise the respective portions of discussion or results.

6. Since relevant information are giving in the respective table, so we did not provide figures.

7. We have compared our finding to the previous mentioned article name International Breastfeeding Journal 9,7(2.014) in the Introduction section of Manuscript

8. We have carefully checked the whole manuscript thoroughly.

# 2. Reviewer Comments:

1. The studies of Bangladesh as well as South East Asia on EBF are added in the line of 79-81.

2. Methodology section was revised thoroughly for proper explanation and understanding.

3. The article was rewriting for making article crispy and easy to understand that were indicated in the Results section

4. The discussion section was edited minutely, carefully and comprehensively.

5. Conclusion is elaborately rewriting based on the findings in terms of knowledge and practices of EBF.

Attachment

Submitted filename: Response to Reviewers.docx

Click here for additional data file.^{(18.5KB, docx)}

PLoS One. doi: 10.1371/journal.pone.0232027.r003

Decision Letter 1

Russell Kabir

7 Apr 2020

Knowledge and practices of exclusive breastfeeding among mothers in rural areas of Rajshahi district in Bangladesh: A community clinic based study

PONE-D-19-28733R1

Dear Dr. Islam,

We are pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it complies with all outstanding technical requirements.

Within one week, you will receive an e-mail containing information on the amendments required prior to publication. When all required modifications have been addressed, you will receive a formal acceptance letter and your manuscript will proceed to our production department and be scheduled for publication.

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With kind regards,

Russell Kabir, PhD

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Reviewers' comments:

PLoS One. doi: 10.1371/journal.pone.0232027.r004

Acceptance letter

Russell Kabir

14 Apr 2020

PONE-D-19-28733R1

Knowledge and practices of exclusive breastfeeding among mothers in rural areas of Rajshahi district in Bangladesh: A community clinic based study

Dear Dr. Islam:

I am pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now with our production department.

If your institution or institutions have a press office, please notify them about your upcoming paper at this point, to enable them to help maximize its impact. If they will be preparing press materials for this manuscript, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information please contact onepress@plos.org.

For any other questions or concerns, please email plosone@plos.org.

Thank you for submitting your work to PLOS ONE.

With kind regards,

PLOS ONE Editorial Office Staff

on behalf of

Dr. Russell Kabir

Academic Editor

PLOS ONE

Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Supplementary Materials

S1 File

(SAV)

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Attachment

Submitted filename: Response to Reviewers.docx

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Data Availability Statement

All relevant data are within the manuscript and Supporting Information files.

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PERMALINK

Knowledge and practices of exclusive breastfeeding among mothers in rural areas of Rajshahi district in Bangladesh: A community clinic based study

Md Masud Rana

Md Rafiqul Islam

Md Reazul Karim

Ahmed Zohirul Islam

Md Akramul Haque

Md Shahiduzzaman

Md Golam Hossain

Roles

Abstract

Background

Objective

Methodology

Results

Conclusions

Introduction

Methods

Design and study population

Simple size determination

Data collection

Outcomes variables

Independent variables

Statistical analyses

Ethics approval and consent to participate

Results

Table 1. Socio-demographic characteristics according to knowledge on EBF.

Table 2. Socio-demographic characteristics according to EBF practices.

Table 3. Effects of socio-economic and demographic factors for knowledge on EBF.

Table 4. Effects of socio-economic and demographic factors for practices on EBF.

Discussion

Conclusions

Supporting information

Acknowledgments

Data Availability

Funding Statement

References

Decision Letter 0

Russell Kabir

Roles

Author response to Decision Letter 0

Decision Letter 1

Russell Kabir

Roles

Acceptance letter

Russell Kabir

Roles

Associated Data

Supplementary Materials

Data Availability Statement

ACTIONS

PERMALINK

RESOURCES

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