Background: Although breastfeeding is almost universal in Ethiopia, only 52% newborns benefited from early
initiation in 2011. Early initiation is one of the recommended interventions for saving newborn lives but its potential
seems not yet realized for Ethiopian newborns and there is a need for continued efforts to increase coverage. To
do so, it is also relevant to focus on consistent and accurate reporting of coverage in early initiation.
WHO recommends the question “how long after birth did you first put [name] to the breast?” in order to assess
coverage in early initiation. It is designed to measure the time after birth when the mother attempted to initiate
breastfeeding regardless of whether breast milk had arrived or not. However, it is unclear how mothers perceive
this question and what their responses of time refer to. In this study, we assessed Ethiopian mothers’ perception
about the question assessing early initiation.
Methods: Cognitive interviews were conducted between April and May 2013 with eligible mothers in Basona and
Debrebirhan woredas (districts), 120 km away from Addis Ababa, Ethiopia.
Results: A total of 49 mothers, most from Basona (n = 36) and the rest from Debrebirhan woredas (n = 13)
were interviewed. No probes or follow on questions were required for mothers to understand what the WHO
recommended question was about. However, further probing was needed to ascertain what maternal responses of
time refer to. Accordingly, mothers’ response about the timing of early initiation was related to the first time the
newborn received breast milk rather than their first attempt to initiate breastfeeding. In addition, considerable probing
was required to approximate and code responses of time based on the WHO coding format because some mothers
were unable to assess time in minutes or hours.
Conclusion: The existing question is not adequate to identify intended attempts of mothers to initiate breastfeeding.
We recommend revising the question as “how long after birth did you first put [name] to the breast even if your breast
milk did not arrive yet?” Standard probes or follow on questions are required to avoid subjective interpretation of the
indicator.