Access to child-feeding counseling service and determinant factors among breastfeeding mothers in Ethiopia: a multilevel complex data analysis of 2019 Ethiopian mini demographic and health survey

Abstract

Background

Inappropriate child-feeding practices lead to child morbidity and mortality in many countries around the world. In many low- and middle-income countries, mothers often lack access to appropriate child-feeding counseling services within healthcare settings. While several studies have examined recommended infant and child feeding practices, there is insufficient information regarding the accessibility of child-feeding counseling services in Ethiopia. Therefore, this study was conducted to assess the accessibility of child-feeding counseling services and determinant factors among breastfeeding mothers in Ethiopia.

Methods

The total weighted samples of 3979 participants were included in this study. The data were taken from the 2019 Ethiopian Demographic and Health Survey (EDHS). A multilevel multivariable logistic regression model was used to identify the determinant factors of child-feeding counseling services. Excel and STATA-14 software were used for the data management and analysis. In the multivariable multilevel analysis, the adjusted odds ratio with a 95% CI was used to declare significant determinants of child-feeding counseling services.

Result

The prevalence of child-feeding counseling services among mothers in Ethiopia during the 2019 EDHS was 36.94%. In multivariable multilevel analysis, the significant factors associated with child-feeding counseling service were wealth index (AOR = 1.46; 95 CI (1.04–2.06)), maternal education; primary education (AOR = 1.27; 95% CI (1.03–1.58)), secondary and higher education (AOR = 1.56; 95% CI (1.17–2.08)), place of delivery; higher odds was observed among mothers who delivered at health institution (AOR = 8.4; 95% CI (6.73–10.49)), marital status; ever married (AOR = 3.28; 95 CI (1.12–9.59)), place of residence (AOR = 2.06; 95% CI (1.39–3.05)), community poverty level; middle (AOR = 1.38; 95% CI (1.07–1.78)), richer (AOR = 1.54 (1.19–1.99)), antenatal care visits; 1–4 visits (AOR = 2.90; 95% CI (2.21–3.84)), 5–8 visits (AOR = 3.33; 95% CI (2.40–4.61)), and more than 8 visits (AOR = 3.40; 95% CI (1.79–6.46)), the regions, Tigray (AOR = 2.65; 95% CI (1.36–5.14)), Afar (AOR = 2.57; 95% CI (1.34–4.92)), Amhara (AOR = 1.94; 95% CI (1.02–3.65)), and Addis Ababa (AOR = 3.9; 95% CI (1.84–8.28)).

Conclusion and recommendation

Child-feeding counseling service among breastfeeding mothers was low and requires immediate attention to promote healthy child-feeding practices by improving the accessibility of the counseling service. The determinant factors were an important input to developing strategies for improving the accessibility of child-feeding counseling services in the country.

Introduction

Providing appropriate child-feeding counseling services and promoting optimal feeding practices for infants and young children are essential for their normal growth and development. Breastfeeding should commence within the first hour after birth and continue up to two years of age or beyond [1]. According to previous studies, early initiation of child breastfeeding within the first hour of birth and adequate counseling about exclusive breastfeeding for the first six months of birth followed by continued breastfeeding for up to two years and beyond with recommended complementary foods is the most appropriate feeding strategy [2–4].

The World Health Organization (WHO) estimated that currently more than 25 million child’s born with low birth weight annually [5]. The low-birth-weight babies’ growth and development will be grossly restricted unless they have accessed appropriate feeding and appropriate child care. In many low- and middle-income countries, mothers often lack access to adequate child-feeding counseling services within healthcare settings. This gap contributes to the prevalence of inappropriate feeding practices, which are significant factors in child morbidity and mortality worldwide. Appropriate child-feeding practices are essential for the health growth, mental development, and overall well-being of the children [6, 7]. Nutritional problems contribute to more than 60% of under-five mortality in the world each year [8]. About two-thirds of child mortality is due to inappropriate child-feeding practices associated with inadequate access to child feeding counseling service [9]. Inadequate and inappropriate child feeding practices lead to serious infections and nutritional problems that cause growth retardations, immunodeficiency cognitive impairments, and eventually fatal outcomes might happen [10, 11].

The main challenges associated with inappropriate child-feeding practices among mothers include inadequate knowledge of recommended child feeding, insufficient understanding of appropriate complementary feeding, cultural influences, and the burden of additional household responsibilities [12]. All these factors are predominantly affected by access to child feeding counseling services inadequacy either in the health care setting or outside the health care setting like community health education or child feeding education through mass media. Adequate child feeding is vital in early childhood to ensure normal growth, and cognitive and mental development, and prevent childhood illness. Appropriate breastfeeding and complementary feeding practices depend on accurate information and support from the family, community, and healthcare system. Inadequate child feeding practices are an equally important determinant of nutritional problems, as is the lack of adequate counseling service [13, 14].

Although numerous studies have explored recommended infant and child feeding practices, there remains a lack of comprehensive information regarding the accessibility of child-feeding counseling services. Consequently, this study was undertaken to evaluate the availability of such counseling services and identify the factors influencing their accessibility among breastfeeding mothers in Ethiopia.

Methods

Study design and setting

In order to identify the determinant factors associated with the accessibility of child-feeding counseling services in Ethiopia, a multilevel analysis study was carried out using the data from the EDHS in 2019. The country is located in the Horn of Africa between 3- and 15-degrees North latitude and 33- and 48-degrees East longitude (3°–15° N and 33°–48°E). Ethiopia has nine regional states: Tigray, Amhara, Afar, Somalia, Oromiya, Benishangul-Gumuz, Gambela, Southern Nation Nationalities and People (SNNP), and Harari, as well as two city administrations: Addis Ababa and Dire Dawa, which make up its administrative system. The regions are further subdivided into 68 zones, 817 districts, and 16,253 Kebeles, the lowest level of administrative entities in the nation.

Source of data, extraction method, sample process, and participants of the study

The source of data for this study was the EDHS 2019 national survey. The EDHS data was collected by the Central Statistics Agency of Ethiopia. Permission was obtained to download the EDHS data sets in STATA format from the Measure DHS website. Two stages of cluster sampling were used to gather and stratify the EDHS samples. After stratifying each region into urban and rural areas, 305 cluster areas (212 rural and 93 urban) were chosen for the first step.

The newly constructed household listing was used to choose a fixed number of 30 households per cluster, with an equal likelihood of systematic selection, for the second step of the selection process. For this study, all mothers who were breastfeeding during the national surveys in the country were the source of population, whereas the study populations were all mothers who were breastfeeding in the selected enumeration areas during the national survey. Finally, a total representative sample of 3,979 breastfeeding mothers was included in this study. The EDHS data was nationally representative [15].

Variables of study

In this study, the dependent variable was the access to child-feeding counseling services. This variable was typically measured as a binary outcome, indicating whether a breastfeeding mother received counseling on child feeding practices (yes or no). The mother’s age, marital status, level of education, wealth index, place of delivery, number of children in the home, frequency of prenatal care visits, and geographic characteristics such as region and place of residence were among the independent variables of the study.

Data management and analysis

Sample weights were applied to adjust for varying selection probabilities across strata and to restore the survey’s representativeness. Multilevel analyses and descriptive statistics were conducted using Stata software, version 14. Using a multilevel multivariable logistic regression analysis, the determinant factors associated with child-feeding counseling service accessibility were identified. Four models were fitted during the multilevel analysis process: the null model, a model without any explanatory variables; model I, a model that contained explanatory variables only at the individual level; model II, which contained explanatory variables only at the community level; and model III, which included explanatory variables at both the individual and community levels. We performed bivariable and multivariable multilevel logistic analyses. Multivariable analysis was conducted for variables in the bivariable analysis with p-values less than 0.2. A statistically significant association was declared at a p-value < 0.05 in the multivariable analysis and presented in the form of an Adjusted Ratio (AOR) with a 95% Confidence Interval (CI).

Result

A total of 3,979 mothers of breastfeeding mothers were included in this study. Among the total, 2,975 (74.77%) of the mothers lived in rural areas, and 2,034(51.12%) of the mothers were in the age category of 25–34 years. About 1,798 (45.1%) of the mothers delivered their child at home. About 2,065 (51.90%) of the mothers have no formal education, and 1,189 (29.88%) of the mothers live in the poorest households. The majority 3,686 (92.64%) of the mothers were married. More than one-fourth (26.24%) of the mothers had no antenatal care visits in the health facility (Table 1).

Table 1.

Socio-demographic characteristics of breastfeeding mothers in Ethiopia, data from EDHS 2019 (n = 3,979)

Variables	Category	Frequency	Percent (%)
Residence	Urban	1,004	25.23
	Rural	2,975	74.77
Age of mother	15–24 year	1,054	26.49
	25–34 year	2,034	51.12
	35–49 year	891	22.39
Educational level of mothers	No education	2,065	51.90
	Primary	1,306	32.82
	Secondary and higher	608	15.28
Marital status of mother	Unmarried	29	0.73
	Married	3,686	92.64
	Ever married	264	6.63
Religion	Orthodox	1,289	32.40
	Protestant	780	19.60
	Muslim	1,862	46.80
	Others	48	1.21
Number of children in Household	No	54	1.36
	1–4	2,772	69.67
	5–10	1,136	28.55
	> 10	17	0.43
Wealth index	Poorest	1,189	29.88
	Poorer	683	17.17
	Middle	586	14.73
	Richer	543	13.65
	Richest	978	24.58
Number of Antenatal care visits	No visit	1,044	26.24
	1–4 visits	2,109	53.00
	5–8 visits	753	18.92
	9 or more visits	73	1.83
Place of delivery	Home	1,798	45.19
	Institution	2,181	54.81
Region	Tigray	346	8.70
	Afar	389	9.78
	Amhara	408	10.25
	Oromiya	491	12.34
	Somali	342	8.60
	Benishangul Gumz	371	9.32
	SNNP	469	11.79
	Gambella	338	8.49
	Harari	307	7.72
	Addis Abeba	236	5.93
	Dire Dawa	282	7.09

Access to child-feeding counseling services among breastfeeding mothers in Ethiopia

In this study, only 36.94% of the participants have accessed a counseling service about child feeding, whereas the rest of the participants did not access any counseling service with a 95% confidence interval (35.45–38.45%) (Table 2).

Table 2.

The prevalence of access to child feeding counseling service among breastfeeding mothers in Ethiopia (n = 3979)

Variable	Category	Frequency	Percent (%)
Access to Child feeding Counseling Service	No	2,509	63.06
	Yes	1,470	36.94

Regional distribution of access to child feeding counseling services in Ethiopia

The accessibility of child-feeding counseling services varies from region to region in Ethiopia.

Addis Ababa, Tigray, Afar, and Amhara regions have better access to child-feeding counseling services for breastfeeding mothers in the country. Other regions like Somali, Dire dawa and SNNPR regions did not have adequate access to child-feeding counseling service for breastfeeding mothers (Fig. 1).

Fig. 1.

Regional distribution of access to child feeding counseling service among breastfeeding mothers in Ethiopia, EDHS 2019 (n = 3, 979)

Multilevel analysis of the determinant factors associated with child-feeding counseling

The total variation in child-feeding counseling services among breastfeeding mothers in the 2019 EDHS was attributable to clustering. The result of the null model showed that there was significant variability in access to child-feeding counseling services. The clustering effect was Intra-Class correlation (ICC) with 95% CI was 0.39 (0.33–0.44) and the Log-likelihood ratio (LLR) was − 2313.0994, which was directed to conduct multilevel analyses to identify the determinant factors associated with child-feeding counseling services among breastfeeding mothers in Ethiopia.

In this study, a multilevel analysis was carried out to identify factors affecting child-feeding counseling services among breastfeeding mothers and presented with an AOR and 95% CI.

At the individual/household level, the significant factors associated with child-feeding counseling service were the wealth index; those mothers from richest households had higher odds of access to counseling service (AOR = 1.46; 95 CI (1.04–2.06)), maternal education; primary education (AOR = 1.27; 95% CI (1.03–1.58)), secondary and higher education (AOR = 1.56; 95% CI (1.17–2.08)), place of delivery; higher odds were observed among mothers who delivered at health institutions (AOR = 8.4; 95% CI (6.73–10.49)), marital status; ever married (AOR = 3.28; 95 CI (1.12–9.59).

At the community level, the significant factors associated with child-feeding counseling service were urban residence; those mothers from urban residence were 2.06 times more likely to access child-feeding counseling service as compared to rural mothers (AOR = 2.06; 95% CI (1.39–3.05)), community poverty level; middle (AOR = 1.38; 95% CI (1.07–1.78)), richer (AOR = 1.54 (1.19–1.99)), regions; Tigray (AOR = 3.98; 95% CI (2.00-7.92)), Amhara (AOR = 2.42; 95% CI (1.26–4.63)), Benishangul Gumz (AOR = 3.03; 95% CI (1.51–6.09)), and Addis Ababa (AOR = 5.36; 95% CI (2.55–11.23)).

In multivariable multilevel analysis, the significant factors associated with child-feeding counseling service were maternal education: primary education (AOR = 1.26; 95% CI (1.02–1.57)), secondary and higher education (AOR = 1.42; 95% CI (1.06–1.91)), the place of delivery, those mothers who deliver in the health institution were 8.3 times more likely to access child-feeding counseling service as compared to home delivery (AOR = 8.3; 95%CI (6.65–10.36)), antenatal care visits; 1–4 visits (AOR = 2.90; 95% CI (2.21–3.84)), 5–8 visits (AOR = 3.33; 95% CI (2.40–4.61)), and more than 8 visits (AOR = 3.40; 95% CI (1.79–6.46)), the regions, Tigray (AOR = 2.65; 95% CI (1.36–5.14)), Afar (AOR = 2.57; 95% CI (1.34–4.92)), Amhara (AOR = 1.94; 95% CI (1.02–3.65)), and Addis Ababa (AOR = 3.9; 95% CI (1.84–8.28)) (Table 3).

Table 3.

Multilevel analysis for the determinant factors associated with access to child feeding counseling service among breastfeeding mothers in ethiopia, EDHS 2019 (n = 3,979)

Variables	Category	Model I	Model II	Model III
Age of mother	15–24 year	0.82(0.63–1.07)	-	0.84(0.61–1.17)
	25–34 year	0.92(0.73–1.14)	-	0.97(0.76–1.24)
	35–49 year	1.0	-	1.0
Wealth index	Poorest	1.0	-	1.0
	Poorer	1.43(0.86–1.91)	-	1.46(1.08–1.97)
	Middle	1.41(0.93–1.94)	-	1.44(1.04–1.98)
	Richer	1.02(0.73–1.41)	-	0.74(0.53–1.04)
	Richest	1.46(1.04–2.06)*	-	0.71(0.43–1.60)
Maternal education	No education	1.0	-	1.0
	Primary	1.27(1.03–1.58)*	-	1.26(1.02–1.57)*
	Secondary and higher	1.56(1.17–2.08)*	-	1.42(1.06–1.91)*
Delivery place	Home	1.0	-	1.0
	Institution	8.4(6.73–10.49)*	-	8.3(6.65–10.36)*
Number of under-five in the household	1	0.91(0.66–1.24)		0.83(0.59–1.14)
	2	1.10(0.61–1.97)	-	1.0(0.72–1.38)
	3–5	1.0	-	1.0
Marital status	Unmarried	1.0	-	1.0
	Married	1.68(0.60–4.69)	-	2.0(0.70–5.68)
	Ever married	3.28(1.12–9.59)*	-	3.89(1.31–11.51)
Antenatal visits	No visit	1.0	-	1.0
	1–4 visits	0.3(0.16–1.56)	-	2.90(2.21–3.84)*
	5–8 visits	0.94(0.53–1.69)	-	3.33(2.40–4.61)*
	> 8 visits	1.10(0.61–1.97)	-	3.40(1.79–6.46)*
Residence	Urban	-	2.06(1.39–3.05)*	1.16(0.82–1.64)
	Rural	-	1.0	1.0
Community illiteracy level	Low	-	1.0	1.0
	High	-	0.54(0.45–1.65)	0.44(0.41–1.42)
Community poverty level	Poorer	-	1.0	1.0
	Middle	-	1.38(1.07–1.78)*	1.54(1.12–2.13)*
	Richer	-	1.54(1.19–1.99)*	1.56(1.08–2.25)*
Region	Tigray	-	3.98(2.00-7.92)*	2.65(1.36–5.14)*
	Afar	-	1.28(0.64–2.58)	2.57(1.34–4.92)*
	Amhara	-	2.42(1.26–4.63)*	1.94(1.02–3.65)*
	Oromia	-	0.86(0.44–1.64)	0.87(0.46–1.64)
	Somali	-	0.39(0.18–1.91)	1.0
	Benishangul Gumz	-	3.03(1.51–6.09)*	1.83(0.95–3.54)
	SNNP	-	1.31(0.68–2.51)	1.31(0.70–2.48)
	Gambella	-	1.95(0.97–3.91)	1.85(0.95–3.59)
	Harari	-	1.0	0.84(0.43–1.66)
	Addis Abeba	-	5.36(2.55–11.23)*	3.9(1.84–8.28)*
	Dire Dawa	-	0.99(050-1.96)	0.73(0.37–1.46)

*Statistically significant at a p-value < 0.05

Discussion

This study evaluated the accessibility of child-feeding counseling services and identified the factors influencing their utilization among breastfeeding mothers in Ethiopia, based on data from the 2019 EDHS. Access to healthcare services plays a pivotal role in determining a country’s maternal and child health outcomes, reflecting the overall effectiveness of its economic and healthcare systems. The accessibility of child-feeding counseling services was affected by the socioeconomic and demographic variables of the participants in the country. International organizations like WHO recommend the appropriate child-feeding counseling service as part of a program in the health care system. The WHO and UNICEF recommend providing infant and young child feeding counseling to caregivers. Integrating counseling services for breastfeeding and complementary feeding mothers into nutrition programs is essential for promoting optimal maternal and child health.

In this study, the prevalence of access to child-feeding counseling services was 36.94% in the 2019 national survey. The magnitude of child-feeding counseling service in this study was lower than in other studies conducted in India 90.1% [16]. This discrepancy might be due to health care system variation between Ethiopia and India. This might also be in this study the data was collected throughout the country including rural communities. But, in India, the study was conducted in small scale sample size. In addition, there is also the variation of socio-demographic, economic, and lifestyle-related differences across the population of Ethiopia and India. The prevalence of access to child-feeding counseling services in this study was higher than in a study conducted in Riyadh Saudi Arabia 31.5% [17]. This discrepancy might be due to variability in the data collection technique. In this study, the data was national survey. But, in Saudi Arabia, the data was collected from social media and online sources rather than interview based or in the health care setting by health care providers.

The factors influencing the accessibility of child-feeding counseling services among breastfeeding mothers in Ethiopia were analyzed at multiple levels. At the individual household level, the wealth index; those mothers from richest households have higher odds of accessibility to child-feeding counseling services as compared to those mothers from poorest households. This finding was supported by other studies conducted in Ethiopia [18]. This might be due to that richest household wealth status can access health care costs, access to transportation to the health care facility, access to health education through online or social media, even can access to private health care provider in their home to access information about feeding for their child, and also have better access to health-related information as compared from poorest households.

This study explores that higher level of maternal education was significantly associated with child-feeding counseling service. Those mothers who had higher educational status have higher odd of access to child-feeding counseling as compared to non-educated mothers. This finding was in agreement with a study conducted in Ethiopia [19] and Vietnam [20]. This might be due to maternal education helping mothers to access information about appropriate child-feeding from written materials and easily understand child-feeding-related information from mass media. Our study found that marital status is a significant determinant influencing the accessibility of child-feeding counseling services among breastfeeding mothers. Evidence indicates that married individuals often prefer home-based care over healthcare facility visits, even during illness [21]. Mothers of ever married had about three times higher odds to access child-feeding counseling service. This might be ever married mothers have an intention to care for their child because they will not have child in the future since their marital status is discontinued.

Place of delivery was one of the significant determinant factors associated with child-feeding counseling services at the individual household levels. Mothers who delivered their children in the health care institution were almost eight times more likely to access child-feeding counseling services as compared to mothers who delivered their children at home. This finding was in line with other studies conducted in Ethiopia [22] and Pakistan [23]. The reason for this situation is clear mothers who deliver their children in the health care institution easily access child-feeding counseling services and can access information related to child care and follow-up, but mothers who deliver to their home cannot access it easily.

At the community level, place of residence was one of the determinant factors associated with access to child-feeding counseling services. Mothers from urban areas were two times more likely to access child-feeding counseling services as compared to rural mothers. This finding was supported by other study conducted in Ethiopia [24]. This might be due to mothers who live in the urban areas being nearer to the health facility to receive child-feeding counseling service as compared to those mothers who live in rural areas and there is also a lifestyle variation between urban and rural residence related to the habit of health care seeking behavior.

This study demonstrated that antenatal care visits to healthcare facilities were positively associated with access to child-feeding counseling services. An increasing number of visits increased the accessibility of child-feeding counseling services in the health facility. Mothers who attended antenatal care visits more than eight times were almost three times more likely to access child-feeding counseling services than non-visitors. This finding was supported by other study conducted in Ghana [25]. This might be during antenatal care visits there is counseling service about the overall maternal and child health provided by the health care personnel as part of health care service. On the contrary, the mothers who did not visit health care facilities do not access the counseling service by the health care providers.

The multilevel analysis in this study showed that the regions of the country were among the determinant factors of child-feeding counseling services in Ethiopia. Mothers from Addis Ababa, Amhara, Afar, and Tigray regions had higher odds of access to child-feeding counseling services than other regions. This finding was supported by other studies conducted in Ethiopia [26]. The regions; Addis Ababa, Amhara, Afar, and Tigray have better access to child-feeding counseling services, this might be because of adequate access to healthcare facilities, adequate infrastructures for transportation to access healthcare information or education, and the population can easily access child health care services as compared to the population of other regions.

Conclusion

Child-feeding counseling service among mothers was low and requires immediate attention to promote healthy child-feeding practices by improving the counseling service accessibility. The significant factors associated with access to child-feeding counseling services were the educational status of mothers: higher odds observed among educated mothers, place of delivery; higher odds of access to child-feeding counseling service among mothers who delivered in the health institution, wealth index; richest-level wealth index had higher odds than poorest, marital status; ever married mothers had higher odds of access to child-feeding counseling service, place of residence: higher odds was observed among urban mothers, and the regions; In Addis Ababa, Amhara, Afar, and Tigray regions observed higher odds of access to child-feeding counseling service. These determinant factors are an important input to develop strategies for improving the accessibility of child-feeding counseling services as well as regional-based interventions in the country.

This study highlights a concerningly low access to child-feeding counseling services among breastfeeding mothers in Ethiopia, with disparities linked to factors such as maternal education, place of delivery, wealth status, marital status, urban residence, and regional differences. To address these gaps, scientific scholars should focus on developing targeted, region-specific interventions that enhance service accessibility. Strategies may include integrating counseling into routine maternal health services, prioritizing outreach in rural and underserved areas, and tailoring programs to support less-educated and economically disadvantaged mothers. Additionally, strengthening community health systems and engaging local stakeholders can promote equitable access to breastfeeding support across diverse populations.

Limitation of the study

This study was conducted based on the data from the 2019 Ethiopian Mini Demographic and Health Survey to explore factors affecting access to breastfeeding counseling. However, its cross-sectional design limits causal inferences, and reliance on secondary, self-reported data introduces potential biases. The scope of variables may not encompass all relevant determinants, such as cultural beliefs or health system nuances. Additionally, while the mini-EDHS aims for national representativeness, certain subpopulations might be underrepresented, affecting generalizability.\.

Abbreviations

AOR

Adjusted Odd Ratio

CI

Confidence Interval

EDHS

Ethiopian Demographic and Health Survey

SNNPR

South Nations Nationalities and Peoples Region

UNICEF

United Nations International Children’s Emergency Fund

WHO

World Health Organization

Author contributions

Author contributions: All authors made a significant contribution to the work reported.M.S.A: contributed to the conception, study design, execution, and acquisition of data, software, and data analysis and gave final approval of the version to be published, T.G.A: contributed to drafting, gave final approval of the version to be published, T.T.T: contributed to study design, and analysis and gave final approval of the version to be published, A.T.G: contributed to revising, gave final approval of the version to be published, B.T: contributed to the interpretation, gave final approval of the version to be published, E.G.M: contributed to the acquisition of data, and interpretation, and gave final approval of the version to be published, M.A.T: contributed to revising, gave final approval of the version to be published, B.S.W: critically reviewing the article, gave final approval of the version to be published, M.W: critically reviewed the article, and gave final approval of the version to be published, A.T.K: contributed to revising, gave final approval of the version to be published, A.F.Z: contributed to software and data analysis critically reviewed the article and gave final approval of the version to be published, All authors gave final approval of the version to be published; have agreed on the journal to which the article has been submitted; and agree to be accountable for all aspects of the work.

Funding

No funding was accepted for conducting the study and preparation of this manuscript.

Data availability

All data are available upon request. The reader could contact the corresponding author for all data accession.

Declarations

Ethics approval and consent to participate

In obtaining the microdata, a request was made on online to the DHS program website http://www.dhsprogram.com on September 10, 2023, and approval was granted to download the; hence, there were no ethical issues of concern. The data used in this study was freely available and did not contain any personal information, no IRB approval needed for this study. The research was done based on a secondary data from EDHS. Issues of informed consent, confidentiality, anonymity and privacy of the study sample already done ethically by the EDHS authority and we did not manipulate and use the data for other issues. There was no patient or public involvement in this study. We have read the BMC Health Services Research journal’s current research ethics guidelines, and accept responsibility for the conduct of the procedures in accordance with the journals. We have attempted to identify all the risks related to this research that may arise in conducting this research, obtained the relevant ethical and/or safety approval (where applicable), and acknowledged our obligations and the rights of the participants by the demography and health survey program authorities. The research is conducted in accordance with the declaration of Helsinki.

Consent for publication

Not Applicable.

Competing interests

The authors declare no competing interests.