This study is reported following STrengthening the Reporting of OBservational studies in Epidemiology (STROBE) guidelines (Additional file 1: Table S1).
Study area and participants
This study was conducted in Lira District (2°14′59.6"N 32°53′59.5"E) in Lango subregion of Northern Uganda. It is approximately 342 km North of Kampala (Uganda’s capital) by road. All other districts in the subregion were carved out of Lira which was originally Lango District. The district share frontiers with Agago and Pader districts to the North, Otuke and Alebtong to the East, Dokolo to the South, Apac and Kwania to the Southwest, and Kole and Oyam to the West. The total population of the district is 408,043, out of which 211,380 (51.8%) are females and 196,663 (48.2%) are males (UBOS 2017). Most women in formal employment in Lira are employed in educational institutions, health facilities and commercial institutions.
Study design and study population
This study was a cross-sectional study which targeted working mothers in 36 health facilities across Lira District. Mothers with infants less than 6 months of age and were living and working in health facilities in the district for over 2 years were the source population.
Inclusion and exclusion criteria
The study included mothers of 18 years and above who have been resident in Lira District for the last 2 years, are formally employed in government or private health facilities, have a biological child below 6 months old, are fluent in English language and were willing to participate in the study. Non-biological, seriously ill mothers (with medical reasons for not breast-feeding), non-consenting mothers and mothers unable to communicate due to hearing loss were excluded from the study.
Sample size determination and sampling procedure
Single population proportion formula (n = z2 p (1 − p)/e2) was used (Kasiulevičius et al. 2006). Using the prevalence of EBF (p) in Uganda = 65.5%, 95% confidence interval (z), 5% marginal error (e) and accounting for 10% non-response rate (Napyo et al. 2020), the sample size was found to be 382.
Based on the proportion of government (52%) versus private (48%) facilities, 19 government and 17 private facilities (out of 48 health facilities) were chosen (Additional file 2: Table S2). Participants were selected by simple random sampling. (199 and 183 participants were selected from government and private health facilities, respectively.)
Operational definitions
Breast-feeding
Feeding of an infant or young child with breast milk either directly from human breasts by suckling or by expressed breast milk.
Early initiation of breast-feeding
Initiating breast-feeding within the first hour of birth.
Pre-lacteal feeding
Cultural practice of giving a newly born child any fluid or semisolid food such as water, black tea, honey, sugar solution, herbal paste, and so forth, before initiating breast-feeding, usually lasting for the first 3 days after delivery.
Exclusive breast-feeding
Mother breast-fed and no other liquids or solids were given, to the child aged less than 6 months in the 24 h prior to the survey, with the exception of oral rehydration solution, supplements or medicines (Adugna et al. 2017).
Continued breast-feeding
The feeding process starting when breast milk alone is no longer sufficient to meet the nutritional requirements of infants, and therefore other foods and liquids are needed, along with breast milk.
Working mother
Mother who is formally employed either by government or by non-government organization on full-time or part-time basis, where the employer has the power or right to control and direct the working mother on how the work is to be performed.
Partial breast-feeding
Giving a baby some breast-feeds, and some artificial feeds, either milk or cereal, or other food (Adugna et al. 2017).
Seriously ill mothers
Working mothers who are either unconscious, unable to give the required information for this study or have medical reasons for not breast-feeding.
Conceptual framework and study measurement of variables
Breast-feeding practices are a product of several factors which influence a woman’s decision to breast-feed or not. The relationship between these factors and how they influence breast-feeding practices is shown in the Conceptual Framework used in this study (Fig. 1).
The dependent variables in this study were the breast-feeding practices, which were measured in terms of giving of pre-lacteal feeds, early initiation of breast-feeding (within 1 hour postpartum) and exclusive breast-feeding for 6 months. These breast-feeding practices are influenced by socio-demographic, work-related as well as obstetric factors which contribute to a woman’s decision to breast-feed. The independent variables were the predictors of breast-feeding practices. These were measured in terms of socio-demographic, work-related and obstetric factors which influence breast-feeding practices. Socio-demographic factors such as mother’s age, level of education, marital status, number of children and income level are believed to influence a mother’s decision to breast-feed or not. Work-related factors such as type of employer, length of daily working time, provision of paid maternity leave, workplace breast-feeding policies such as provision of breast-feeding breaks and space for breast-feeding influence the breast-feeding practices of the working mothers. Furthermore, obstetric factors such as number of antenatal visits, receiving breast-feeding counselling, place and type of delivery influence the breast-feeding practices adopted by working mothers.
Knowledge and attitude of mothers regarding breast-feeding are the mediating variables in this study. They strengthen or weaken the influence of the predictors of breast-feeding (socio-demographic, work-related and obstetric factors) on breast-feeding practices. Good knowledge about breast-feeding and a positive attitude of mothers improve the likelihood of them adopting good breast-feeding practices and vice versa.
Data collection
Data were collected by trained research assistants using a pretested interviewer-administered questionnaire in English. The questions were constructed based on previous studies (Napyo et al. 2020). The questionnaire had socio-demographic variables and breast-feeding practices: PLF, EIBF and EBF.
Data analysis
Data were manually checked, coded and entered in Stata 15 (StataCorp, College Station, Texas, USA). Descriptive statistics were then used to summarize the data (Napyo et al. 2020). Association between socio-demographic characteristics, work-related and obstetric factors was investigated using chi-square test. Variables that were significantly associated were considered for multivariate logistic regression (at p < 0.05) to determine the potential predictors of breast-feeding practices.