Comparative analysis of different maternal recall methods for assessing exclusive breastfeeding in the Southern Nations Nationalities and People’s Region, Ethiopia Público

Tewodros, Tsedenia (Fall 2019)

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Background: Exclusive breastfeeding (EBF) for the first 6 months of life reduces morbidity, mortality, diarrhea and respiratory tract infections among infants and protects from exposure to suboptimal water and sanitation conditions at an early age. The WHO recommends EBF for 6 months. EBF can be assessed through surveys that rely on maternal recall (such as 24-hour, 7-day and since-birth recall surveys). Point-in-time surveys like the 24-hour and 7-day recalls do not capture EBF for the full 6 months while since-birth recalls are prone to recall bias. This study aims to investigate differences between the three maternal recall methods and to understand whether any sociodemographic factors are associated with discordance between methods.

Methods: Data were collected from SNNPR, Ethiopia. Exclusive breastfeeding was assessed using the 24-hour and 7-day recalls at baseline and the since-birth recall at midline. Overall prevalence of EBF and prevalence by age was calculated and compared. Two-by-two tables were used to compare EBF classification across methods and to determine discordance between the 24-hour and since-birth recalls. Logistic regression was used to examine any associations between sociodemographic characteristics and discordance.

Results: 509 households were included in the analytic sample. EBF prevalence was 80.6%, 79.6%, and 74.7% using the 24-hour, 7-day, and since-birth recalls respectively. The 24-hour and since-birth recalls disagreed on EBF classification of 26% of the sample. The 24-hour and 7-day recalls showed decreasing EBF trends with increasing age. The since-birth recall showed lower rates of EBF in the first month compared to the other two methods. Foods and liquids such as hamesa, water, traditional foods and juice were reported at a higher rate using the since-birth recall than the other two methods. Child’s age at baseline and district of residence were significantly associated with discordance.

Conclusions: Although overall prevalence was similar across methods, there were differences by age. The point-in-time methods may be missing foods introduced in the early months. Measurement methods should be selected based on the purpose of assessment and include more rigorous assessments of foods given in the first month of life. 

Table of Contents

Abstract. iv

Acknowledgements. vi

List of Acronyms. ix

Chapter 1: Literature Review.. 1

Benefits of Exclusive Breastfeeding. 2

Global Trends of Breastfeeding. 4

Measurement and Assessment of Exclusive Breastfeeding. 6

Social Desirability and Recall Bias in Reporting EBF Status 9

Implications for Policy and Programming. 10

Exclusive Breastfeeding Statistics in Ethiopia. 11

Aims and Objectives of the Study. 13

Chapter 2: Manuscript. 14

Contribution of the student. 14


Benefits of Exclusive Breastfeeding. 17

Measurement and Assessment of Exclusive Breastfeeding. 18

Bias in exclusive breastfeeding measurement 19

Exclusive breastfeeding in Ethiopia. 19

Aims and Objectives of the Study. 19


Study Design: 20

Study Setting and Participants: 20

Intervention Components 22

Survey Instruments: 23

Baseline 23

Midline 23

Outcome of Interest and Determinants. 24

Data Analysis 24

Ethical Considerations 25

Limitations 26



Strengths and Limitations 36

Conclusions and Future Recommendations: 37

Chapter 3: Conclusions, Future Recommendations and Public Health Implications. 39

Summary. 39

Bigger Picture and Recommendations 39

Public Health Implications 40

References. 41

Appendix 1: Supplemental Table. 44

Appendix 2: Baseline Exclusive Breastfeeding Questionnaire. 45

Appendix 3: Midline Exclusive Breastfeeding Questionnaire 46

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