Breastfeeding techniques and associated factors among primiparous mothers: A multicenter health facility-based cross-sectional study in Northeast Ethiopia

Abstract

BACKGROUND

Breastfeeding technique (BFT) is a skill that mothers develop over time, and ineffective techniques can contribute to non-exclusive breastfeeding. There is limited evidence on breastfeeding practices and their determinants in Wollo, Ethiopia.

AIM

To assess effective BFT and associated factors among primiparous mothers in Northeast Ethiopia.

METHODS

A multicenter, facility-based cross-sectional study was conducted from July to August 2023, including 415 primiparous mothers selected via systematic random sampling. Data were analyzed using SPSS version 26, and logistic regression was employed to identify factors associated with effective BFT (P < 0.05).

RESULTS

Only 42.9% (95% confidence interval [CI]: 38.1-47.7) of mothers demonstrated effective BFT. Significant factors associated with effectiveness included antenatal counseling [adjusted odds ratio (AOR): 4.38; 95%CI: 2.25-8.51], breast problems (AOR: 9.95; 95%CI: 4.04–24.52), postnatal counseling (AOR: 2.75; 95%CI: 1.43-5.28), timely initiation of breastfeeding (AOR: 3.59; 95%CI: 1.74-7.72), and prior exposure to breastfeeding information (AOR: 3.55; 95%CI: 2.16-5.84).

CONCLUSION

Less than half of primiparous mothers practice effective BFT. Counseling during antenatal and postnatal care, early initiation of breastfeeding, and prior information on breastfeeding are key factors influencing proper technique.

Key Words: Breastfeeding techniques; Primiparous mothers; Maternal factors; Infant feeding; Health facilities; Cross-sectional study

Core Tip: Effective breastfeeding techniques are crucial for infant nutrition but are often inadequately practiced, especially among first-time mothers. This multi-center study in Northeast Ethiopia found that less than half of primiparous mothers demonstrated correct techniques. Key factors influencing effective breastfeeding included antenatal and postnatal counseling, timely initiation, breast problems, and prior exposure to breastfeeding information. These findings highlight the need for targeted education and support interventions at health facilities to improve breastfeeding practices, which can ultimately enhance maternal and infant health outcomes in similar low-resource settings.

INTRODUCTION

Effective breastfeeding technique (BFT) is fundamental to successful breastfeeding and optimal infant nutrition. It comprises three interrelated components: Appropriate positioning of the infant, adequate attachment to the breast, and effective suckling, all of which are essential for efficient milk transfer and maternal comfort[1]. Positioning refers to how the infant is aligned and supported in relation to the mother’s body, while attachment describes the infant’s ability to take sufficient areola and breast tissue into the mouth. When correct positioning and attachment are achieved, effective suckling is facilitated, resulting in successful breastfeeding[2,3].

The practice of effective BFT plays a crucial role in establishing and sustaining breastfeeding, preventing breastfeeding-related complications, and ensuring adequate nutritional intake for infants[1]. Although breastfeeding is a natural physiological process, effective BFT is not entirely instinctive and requires learned skills and appropriate support[4]. Mothers who acquire adequate knowledge and skills related to BFT are better able to prevent and manage common breastfeeding problems, particularly during the early postnatal period[5]. Evidence indicates that many breastfeeding difficulties can be avoided when proper positioning and attachment are achieved during the initial feeds[5]. In contrast, ineffective BFT has been strongly associated with nipple pain and soreness, which are among the leading causes of early breastfeeding discontinuation[6,7]. Studies from India have shown that ineffective BFT was present in 57% and 63% of infants suffering from diarrhea and acute respiratory infections, respectively, highlighting its broader health implications[6].

Ineffective BFT can result in inadequate breast milk intake, leading to poor weight gain, growth faltering, and stunting in infants. Poor positioning, attachment, and suckling are also associated with reduced exclusive breastfeeding (EBF) rates and an increased risk of breastfeeding complications[4]. Cracked nipples, nipple trauma, and mastitis are significantly more common among mothers who practice ineffective BFT, particularly those with poor attachment and positioning[6,8]. Moreover, breastfeeding-related problems have been reported to occur more than twice as frequently among mothers practicing ineffective BFT compared to those practicing effective techniques[5].

Globally, ineffective BFT remains a common challenge, particularly among primiparous mothers, who often lack prior breastfeeding experience. This problem contributes substantially to suboptimal breastfeeding practices, inadequate milk intake, malnutrition, and preventable infant morbidity and mortality[4,6]. Evidence from Western Denmark indicates that approximately 39% of mothers practiced ineffective BFT[9]. Similarly, studies conducted in tertiary hospitals in North Karnataka reported that nearly 59% of primiparous mothers practiced ineffective BFT[2,3,10]. Research from Delhi has also demonstrated inadequate BFT among first-time mothers[5]. In the African context, a study from Libya reported a high prevalence of ineffective BFT, characterized mainly by poor positioning and attachment[8]. In Ethiopia, several studies conducted in different regions have consistently documented a high prevalence of ineffective BFT among lactating mothers[11-15]. Collectively, these findings underscore that ineffective BFT is a widespread and significant public health concern that warrants further investigation.

Several interventions have been proposed to address ineffective BFT, including maternal education and counseling on proper breastfeeding practices, capacity building of healthcare providers in breastfeeding support, and targeted interventions for young and first-time mothers[4]. Evidence suggests that training healthcare providers and delivering continuous breastfeeding education through counseling sessions, educational materials, and practical demonstrations can substantially improve the practice of effective BFT[6]. In line with this, Ethiopia’s Integrated Management of Childhood Illness guidelines emphasize the importance of educating and counseling mothers on effective BFT while discouraging the introduction of supplementary feeding before six months of age[4].

Despite these recommendations, timely and context-specific evidence on BFT practices remains limited, particularly among primiparous women. Understanding BFT practices in this population is essential for improving breastfeeding effectiveness and neonatal health outcomes. In Ethiopia, comprehensive data on BFT among first-time mothers are scarce, highlighting a critical knowledge gap. Therefore, this study aimed to assess BFT practices and identify factors associated with effective breastfeeding among primiparous mothers attending public health facilities in Northeast Ethiopia.

MATERIALS AND METHODS

Study area and period

This study was conducted in government health facilities in Sekota town from July 7 to August 7, 2023. Sekota, the administrative center of the Waghimera Zone, is located 436 km from Bahir Dar, the capital of the Amhara Regional State, and 720 km from Addis Ababa, the capital city of Ethiopia.

Study population

The study population comprised primiparous breastfeeding mothers attending government health facilities in Sekota town.

Study design

A multi-center facility-based cross-sectional study design was employed to assess the prevalence of BFT and identify factors associated with their practice among primiparous mothers.

Eligibility criteria

The inclusion criteria were primiparous mothers who had delivered at term (≥ 37 weeks of gestation), were less than six months postpartum, and had initiated breastfeeding. Mothers who were severely ill during data collection or had cracked nipples or other medical conditions that contraindicated breastfeeding were excluded.

Sample size determination

The sample size was calculated using the single-population proportion formula, based on an estimated prevalence of effective BFT of 43.4% among women[2]. A 95% confidence level and a 5% margin of error were applied. The formula used was: n = (Z_a/2)² × (p) (q)/d², where n is the required sample number, α is the significance level (5%), Z_a/2 is Z (standard normal distribution value) at designated level of significance (1.96), p is the expected proportion of females practicing effective BFT (43.4%), and d is the margin of error (0.05). The sample size was calculated as follows: n = (1.96)² × (0.43 × 0.57)/(0.05)² = 377. After accounting for a 10% non-response rate, the final sample size was adjusted to 415 participants.

Sampling technique

The study was conducted in two health facilities, with the total sample size proportionally allocated between them. The average number of mothers attending the Expanded Program on Immunization unit at each facility over the past three months was obtained from client registration records to estimate the expected client flow during the study period, which was 841 mothers. The sampling interval (k) was calculated by dividing the expected number of mothers (N) by the sample size (n): K = N/n = 841/415 = approximately 2.

Using a systematic random sampling technique, every second mother-infant pair was selected until the required sample size was reached.

Data collection procedure

Data were collected using a structured questionnaire developed after a thorough review of relevant peer-reviewed literature[10,15-18]. Both a structured interview and an observational checklist were employed. The questionnaire was initially prepared in English, translated into Amharic (the local language), and subsequently back-translated to ensure accuracy. It comprised four sections: The first captured socio-demographic characteristics of the respondents; the second and third addressed maternity and maternal/infant health service utilization, as well as maternal and infant health-related factors; the fourth section assessed BFT.

The BFT assessment checklist was adapted from previously published standardized breastfeeding observational guidelines evaluating positioning, attachment, and suckling components. These tools have been widely utilized in similar maternal and child health studies. To enhance consistency and reduce observer variability, data collectors received structured training on the application of the checklist and scoring procedures before data collection.

Operational definitions

Breast problems: Breast problems refer to any issues arising during breastfeeding[19], including: (1) Engorgement: Painful swelling of the breast due to inadequate milk expression; (2) Cracked nipples: Breaks or fissures in the nipple skin; (3) Inverted nipples: Nipples that retract inward rather than protruding outward; and (4) Sore nipples: Pain experienced in the nipple and areola during breastfeeding.

Primipara: Mothers who have given birth once and have an infant less than six months old.

BFT: The overall practice encompassing positioning, attachment, and suckling[20].

Effective BFT: Effective BFT was identified as the fulfillment of at least two out of four positioning criteria (grade 2), three out of four attachment criteria (grade 3), and two out of three suckling criteria (grade 2) during breastfeeding[20].

Ineffective BFT: Ineffective BFT was identified when none or only two out of four criteria for positioning, none or only one out of four criteria for attachment, and none or only one out of three criteria for suckling were fulfilled[20].

Study variables

The dependent variable was the practice of effective BFT. Independent variables included maternal socio-demographic characteristics, maternal and infant-related factors, and obstetric and health service-related factors.

Data quality assurance

Data collectors were experienced health professionals trained on the study objectives, interview techniques, observational procedures, and ethical considerations. The questionnaire was carefully designed based on literature review and translated into Amharic by native speakers to ensure clarity and cultural appropriateness. Collected data were reviewed daily by the research team for completeness, consistency, legibility, and accuracy prior to entry into the database for statistical analysis.

Statistical analysis

Data were checked for completeness, coded, entered into EpiData version 3.2, and then exported to SPSS version 26 for analysis. Descriptive statistics were used to summarize the data. Variables with a P value < 0.25 in bivariable logistic regression were included in a multivariable logistic regression model to identify independent associations. Adjusted odds ratios (AOR) with 95% confidence intervals [CIs] were reported, and statistical significance was set at P < 0.05.

Ethical considerations

Ethical clearance was obtained from the Zemen Postgraduate College Research Ethical Committee, with an official approval code. Written informed consent was obtained from all eligible participants, and all procedures were conducted in accordance with ethical principles for research involving human subjects.

RESULTS

Socio-demographic characteristics

Most participants were aged ≤ 25 years (83.5%) and identified as Orthodox Christians (95.2%). Families typically consisted of three to four members (90.2%), and the majority of mothers (59.5%) had infants older than six weeks. Only 9.4% reported a monthly household income above 3500 Ethiopian birr (Table 1).

Table 1 Socio-demographic characteristics of primiparous mothers.

Variable		n	Percentage (%)
Age of mother	≤ 25	347	83.6
	26-35	68	16.4
Religion	Orthodox	396	95.2
	Others	19	4.8
Family number	1-2	20	4.8
	3-4	375	90.4
	≥ 5	20	4.8
Sex of baby	Male	192	46.3
	Female	223	53.7
Age of baby	1 week	22	5.3
	2-3 weeks	67	16.1
	4-6 weeks	80	19.2
	> 6 weeks	246	59.28
Monthly income	< 1500	211	50.84
	1551-3500	165	39.6
	> 3500	39	9.4

Obstetric and health service utilization

Antenatal care was received by 34.5% of mothers, all of whom reported receiving counseling on breastfeeding practices. Most deliveries (63.3%) occurred at health centers. Postnatal care attendance was 35.7%, with guidance on BFT provided during visits. Early initiation of breastfeeding (within the first hour) occurred in 86.3% of cases, and EBF was practiced by 88.7 % (Table 2).

Table 2 Obstetric and health service utilization among primiparous mothers.

Variable		n	Percentage (%)
ANC follow-up	Yes	143	34.5
	No	272	65.5
ANC counseling about BFT	Yes	143	34.5
	No	272	65.5
Place of birth	Hospital	67	16.1
	Health center	262	63.1
	Private clinic	21	5.1
	Home	65	15.7
PNC follow-up	Yes	148	35.7
	No	267	64.3
PNC counseling about BFT	Yes	148	35.7
	No	267	64.3
First breastfeed initiation	Within 1 hour	357	86
	After 1 hour	58	14
EBF	Yes	369	88.9
	No	46	11.1

BFT: Breastfeeding techniques; EBF: Exclusive breast feeding; PNC: Postnatal care; ANC: Antenatal care.

Maternal and infant-related factors

Breastfeeding challenges were reported by 14.1% of mothers, including issues such as cracked nipples. Approximately 30.9% of participants received family support for breastfeeding, whereas 63.3% had no prior knowledge of proper BFT (Table 3).

Table 3 Maternal and infant-related factors.

Variable		n	Percentage (%)
Breast problem	Yes	58	14
	No	357	86
Family support	Yes	128	30.8
	No	287	69.2
Previous information	Yes	152	36.6
	No	263	63.4

Breastfeeding practice

The prevalence of effective BFT was 43% (95%CI: 38.1-47.7). When examining specific components of technique, notable variations emerged: 33.1% of participants demonstrated good positioning, while 45.3% were average and 21.6% were poor. Similarly, for attachment, 28.9% were classified as good, with the remainder distributed as average (44.6%) and poor (26.5%). In terms of suckling, more than half of the participants (55.9%) had poor suckling scores (Figure 1).

Figure 1 Distribution of breastfeeding technique components among primiparous mothers. A: Overall breastfeeding technique effectiveness; B: Positioning score; C: Attachment score; D: Sucking score. BFT: Breastfeeding technique.

Factors affecting BFT

Bivariate analysis identified variables with P < 0.25, including family support, antenatal counseling, mode and place of delivery, initiation of breastfeeding, breast problems, postnatal counseling, and prior knowledge of BFT. These were included in multivariable logistic regression (Figure 2). Multivariable analysis revealed several independent predictors of effective BFT (P < 0.05): Antenatal counseling on breastfeeding (AOR = 4.38, 95%CI: 2.25-8.51), absence of breast problems (AOR = 9.95, 95%CI: 4.04-24.52), postnatal counseling on breastfeeding (AOR = 2.75, 95%CI: 1.43-5.28), early initiation of breastfeeding (AOR = 3.59, 95%CI: 1.74-7.72), and prior knowledge of BFT (AOR = 3.55, 95%CI: 2.16-5.84).

Figure 2 Forest plot showing factors associated with effective breastfeeding technique among primiparous mothers. The X-axis represents adjusted odds ratio (AOR) on a logarithmic scale, and the Y-axis represents explanatory variables (antenatal care counseling, breast problems, postnatal care counseling, etc.). Each dot represents the AOR, and the horizontal line indicates the 95% confidence interval. Reference categories are indicated where applicable. BFT: Breastfeeding technique; PNC: Postnatal care; ANC: Antenatal care.

DISCUSSION

In this study, less than half of primiparous mothers (42.93%; 95%CI: 38.1-47.7) practiced effective BFT. This finding is comparable with reports from Western Denmark, Belgaum in North Karnataka, and Harar, Ethiopia[1,8,10,20-23]. However, it contrasts with studies conducted among primiparous women in East Delhi, South Ari district, and Southern Ethiopia, where either higher or lower prevalence estimates were reported[6,9]. Such discrepancies may reflect variations in socio-cultural norms, maternal health service utilization, breastfeeding support systems, and the timing and settings of the respective studies. Moreover, the prevalence of effective BFT observed in this study is notably lower than that reported from Gondar, Ethiopia[24], which may be attributable to differences in the availability and quality of maternal health services, particularly antenatal and postnatal breastfeeding counseling.

The present study also demonstrated suboptimal levels of correct infant positioning, attachment, and suckling among primiparous mothers. The proportions of poor positioning and attachment observed are consistent with findings from Libya[25], suggesting that ineffective BFT remains a common challenge across diverse settings. In contrast, the proportion of mothers achieving good positioning, attachment, and suckling in this study was lower than that reported in Eastern Ethiopia[20]. These variations may be explained by differences in maternal education, prior exposure to breastfeeding information, parity-related experience, and methodological differences across studies.

Several factors were identified as significant predictors of effective BFT, including antenatal counseling, postnatal counseling, early initiation of breastfeeding, absence of breast problems, and prior knowledge of BFT. Mothers who received postnatal counseling were nearly three times more likely to practice effective BFT compared to those who did not. This finding is consistent with previous studies conducted in Ethiopia[19,20] and underscores the critical role of postnatal counseling in reinforcing proper breastfeeding skills during the early postpartum period, when breastfeeding difficulties are most common.

The absence of breast problems was also strongly associated with effective BFT. Mothers without conditions such as breast engorgement, nipple soreness, cracked nipples, or inverted nipples were significantly more likely to practice effective BFT. This finding is in agreement with evidence from multiple studies conducted in different settings[10,20,24,26-30]. Breast-related problems can cause pain and discomfort, hinder correct infant attachment and positioning, and reduce the frequency and effectiveness of breastfeeding. Therefore, early identification and management of breast problems are essential to support effective breastfeeding practices among primiparous mothers.

Early initiation of breastfeeding was another important determinant of effective BFT. Primiparous mothers who initiated breastfeeding within the first hour after delivery were more likely to practice effective BFT than those who initiated later. This finding is supported by previous studies conducted in Ethiopia[30,31] and highlights the importance of immediate breastfeeding initiation in facilitating early mother–infant bonding, improving breastfeeding skills, and promoting EBF.

Furthermore, antenatal counseling emerged as a key predictor of effective BFT. Mothers who received breastfeeding counseling during ANC were significantly more likely to practice effective BFT, consistent with findings from earlier studies[3,31]. Antenatal counseling provides an essential platform for educating expectant mothers about breastfeeding, addressing misconceptions, and preparing them for practical challenges related to positioning, attachment, and suckling after delivery.

Finally, prior exposure to breastfeeding information was positively associated with effective BFT. Primiparous mothers who had received information on BFT from any source were more likely to demonstrate effective breastfeeding practices. This finding aligns with evidence from other studies[3,30-32] and suggests that access to accurate breastfeeding information enhances maternal confidence and competence in infant feeding. Exposure to breastfeeding education through healthcare providers, community programs, or media may therefore play a critical role in improving BFT among first-time mothers[33].

CONCLUSION

This study demonstrated that fewer than half of primiparous mothers practiced effective BFT, indicating a substantial gap in optimal breastfeeding practices in Northeast Ethiopia. Antenatal and postnatal breastfeeding counseling, early initiation of breastfeeding, prior exposure to breastfeeding information, and the absence of breast-related problems were significant factors associated with effective BFT. These findings highlight the need to strengthen breastfeeding counseling and support across the continuum of maternal healthcare, particularly for first-time mothers. Integrating practical breastfeeding education into routine antenatal and postnatal services, promoting early initiation of breastfeeding, and improving early identification and management of breast problems may contribute to improved BFT practices. Further longitudinal and interventional studies are recommended to confirm these findings and to inform targeted strategies aimed at improving breastfeeding outcomes in similar settings.

ACKNOWLEDGEMENTS

The authors would like to express their sincere gratitude to Zemen Postgraduate College for its support of this study. They also acknowledge the contributions of the data collectors and extend their appreciation to all study participants for their time and cooperation.