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Determinants of inadequate minimum dietary diversity among children aged 6–23 months in Ethiopia: secondary data analysis from Ethiopian Demographic and Health Survey 2016

  • 1Email author,
  • 1,
  • 2,
  • 3 and
  • 2
Agriculture & Food Security20187:66

https://doi.org/10.1186/s40066-018-0219-8

  • Received: 31 July 2018
  • Accepted: 12 September 2018
  • Published:

Abstract

Background

Inadequate feeding practices are a significant reason for the onset of malnutrition in young children, and their consequences are one of the major obstacles to sustainable socioeconomic development and poverty reduction. Dietary diversity is one of the useful indicators to assess the nutrient adequacy and can examine how different food groups contribute to the nutrient adequacy of the diet in a specific area. Minimum dietary diversity is the intake of at least four food types from the seven categories.

Methods

Secondary data analysis of Ethiopian Demographic health survey of 2016 was conducted to explore significant predictors that make children inappropriate to meet minimum dietary diversity. There were 2972 weighted samples, and we have used “SVY” command by STATA 14.0 during data analysis to run the complex survey data. This study has identified the possible factors of inadequate minimum dietary diversity of children.

Results

The proportion of inadequate minimum dietary diversity in Ethiopia was found 85.1%. Frequency of reading newspaper or magazine, frequency of listening to radio, father’s educational level and household wealth index were found significant predictors to determine the minimum dietary diversity of children. Dairy products and grain, roots and tubers account more than half of consumed foods. Among breastfed children who attained minimum dietary diversity, majority of them were in the age group of 6–11 months.

Conclusions

Minimum dietary diversity is still low in Ethiopia, and most of mothers feed their child the most and easy accessible food rather than of diverse food. In the way of addressing the Sustainable Development Goal, Ethiopia requires substantial improvement in complementary feeding practices. Appropriate infant and young child feeding messages should to be developed and delivered through mass media.

Keywords

  • Minimum dietary diversity
  • EDHS
  • Inappropriate complementary feeding
  • Food groups

Background

Globally, inadequate feeding practices and their outcomes are still one of the real impediments to sustainable socioeconomic development and poverty reduction. Countries will not be productive in their endeavors to quicken economic development in any significant long haul sense until optimal child growth and development, particularly thorough appropriate feeding practices, are ensured [1]. In addition, inappropriate feeding practices are a significant reason for the onset of malnutrition in young children [2].

Adequate nutrition allows children to grow, develop, learn, play, participate and contribute, while under nutrition robs children of their futures and leaves young lives hanging in the balance. Stunting is one of the main reasons that may make children never grow to their full height, and their brains may never develop to their full cognitive potential [3]. Universally, 151 million children younger than 5 years old were stunted (too short for their age) during 2017, with 75% of such children living in the WHO African Region or World Health Organization (WHO) South East Asia Region. During the year of 2017, 51 million children under the age of five were wasted (too light for their height) which is also a major cause of burden preventing children who survive from reaching their full development potential [4].

Except if massive improvements in child nutrition are made, it will be hard to accomplish the ambitious Sustainable Development Goals (SDGs) which target by 2030 to end all types of malnutrition, including achieving, by 2025, the universally agreed targets on reduction of stunting and wasting in children younger than 5 years of age, and address the nutritious needs of adolescent girls, pregnant and lactating women and older persons [4].

Because of the rapid rate of growth and development during the first 2 years (“critical window”), nutrient needs per body weight of infants and young children are high which makes breast milk insufficient to provide all the needs [2]. Complementary feeding is defined as the process starting other foods and liquids, along with breast milk, when breast milk is no longer sufficient to meet the nutritional requirements of infants. Even though breastfeeding may continue beyond 2 years, the target range for complementary feeding is generally taken to be 6–23 months of age [5].

World Health Organization published document in 2008 presented fifteen indicators to assess infant and young child feeding practice that includes eight cores (early initiation of breastfeeding, exclusive breastfeeding under 6 months, continued breastfeeding at first year, introduction of solid, semisolid or soft foods, minimum dietary diversity, minimum meal frequency, minimum acceptable diet and consumption of iron-rich or iron-fortified foods) and seven optional indicators (children ever breastfed, continued breastfeeding at second years, age-appropriate breastfeeding, predominant breastfeeding under 6 months, duration of breastfeeding, bottle-feeding and milk feeding frequency for non-breastfed children). Indicators for dietary diversity (a proxy for adequate micronutrient-density of foods and liquids other than breast milk), feeding frequency (a proxy for adequate energy intake from non-breast milk sources) and minimum acceptable diet among breastfed and non-breastfed children aged between 6 and 23 months were categorized as the cores list. From these indicators, minimum dietary diversity assesses food intake among children age 6–23 months from at least four food groups. Using four food groups as the cutoff is linked with better-quality diets for both non-breastfed and breastfed children [5].

Dietary diversity is one of the useful indicators to assess the nutrient adequacy. It is also able to examine how different food groups contribute to the nutrient adequacy of the diet in a specific area [6]. Besides, dietary diversity is a significant predictor of stunting which enables interventions aimed at improving it can play a pivotal role in reducing the long-term burden of stunting among infants and young children [7]. Generally, the nutritional status of children can significantly be determined by the dietary diversity [8].

Most of developing countries are poorly practicing complementary feeding and are even worsening in some of them [9]. In 2005, Productive Safety Net Program (PSNP) was established by the government of Ethiopia, world food program and development partners collaboratively to increase families’ long-term resilience to food shortages. The birth of PSNP is gone for empowering the rural poor confronting chronic food insecurity to oppose shocks, make resources and move toward becoming sustenance independent. The impact of PSNP was assessed in 2008 and showed some positive effect on a livelihood and food security [10].

All things considered, Ethiopia has been attacked by El Nino related drought since 2015 which greatly increased food insecurity level and malnutrition rate particularly worsen in some regions. One of the worst droughts in decades (El Nino) brings failure of the main rainy season which is vital for producing more than 80% of Ethiopia’s agricultural yield—in a main sector that more than 80% of the country’s populations rely on [11, 12]. The current study aimed to explore the predictors of poor complementary feeding by using MDD and provide some critical insights for policy makers as well as helps further research to explore the current situation, trends and reasons for failure of interventions.

Methods

Source of data

The present study examined the 2016 Ethiopia Demographic and Health Survey (2016 EDHS), which is the fourth in a series of Demographic and Health Surveys conducted in Ethiopia in 2000, 2005 and 2011. The 2016 EDHS sample is stratified and was selected in two stages. Administratively, Ethiopia is divided into 11 geographic regions. Each region was stratified into urban and rural areas, which yielded 21 sampling strata. In the first stage, 645 enumeration areas (EAs) were selected with probability proportional to the EA size and with independent selection in each sampling stratum. An EA is a geographic area that covers an average of 181 residential households as determined in the 2007 Population and Housing Census. In the second stage of selection, a fixed number of 28 households for every cluster were selected with an equal probability systematic selection from the newly created household listing.

The survey had a total of 18,008 households selected for the sample, of which 17,067 were available. Of the available households, 16,650 were successfully interviewed which provides a response rate of 98%. In the interviewed households, there were 16,583 eligible women for individual interviews. Successful interviews were conducted among 15,683 women, yielding a response rate of 95%. Women who had no less than one child living with them who was born in 2014 or later were asked questions about the types of liquids and foods the child had consumed during the day or night before the interview. Mothers who had more than one child born in 2014 or a later year were asked questions about the youngest child living with them [14]. Our analysis was done among last born living children aged 6–23 months, living with the respondent (ever married women of 15–49 years and usual residents), total weighted sample size was 2972.

Variables

Outcome variable

The MDD is defined as the proportion of children aged 6–23 months who consumed foods from at least four food groups out of the seven referenced food groups within a 24-h time. The seven food groups are: 1—grains, roots and tubers, 2—legumes and nuts, 3—dairy products, 4—flesh foods (meat, fish, poultry and liver/organ meats), 5—eggs, 6—vitamin A-rich fruits and vegetables and 7—other fruits and vegetables [4]. In the present study, those children between 6 and 23 months who have taken at least four food groups in the last 24 h before interview are considered as they achieved the MDD adequately. Therefore, the outcome variable is categorized as (“0”—adequate minimum dietary diversity, “1”—inadequate minimum dietary diversity).

Explanatory variables

The explanatory variables were found from different literature and grouped as characteristics of the child, parental, family/household, healthcare services and the community. The child characteristics included sex, age [5], birth order and having common childhood illnesses, and the paternal characteristics included for each parent’s educational level, literacy level, working status and mother’s age, and maternal marital status. The household source of drinking water [13], wealth index and exposure to media were considered as key household characteristics, whereas the nature of residence (urban or rural) was considered as community-level variable. As health service characteristics antenatal visits, place of delivery and timing of post-natal care were included. The information about variables had been described in detail in the EDHS report [14].

Statistical analysis

Complementary feeding indicator (outcome variable) was dichotomized with category 1 for not meeting the indicator criteria and category 0 for meeting the indicator criteria. After the data cleaning is conducted intensively, the outcome variable was examined against different set of independent variables (individual, parental, household, healthcare and community-level characteristics) to identify factors associated with not meeting the indicator criteria. Data analysis was performed by considering sampling weight, and the survey “SVY” commands of Stata version 14.0 were used for adjustments of DHS’ complex sampling design when estimating confidence intervals. The analysis of factors is conducted using sampling weights which denote the inverse of the probability that the observation is included because of the sampling design. Bivariate logistic regression was used to examine the impact of each independent variable on the outcome. Variables that satisfied the cutoff point of p value ≤ 0.25 became candidate for the multiple logistic regression model. But those variables with statistical significance of p < 0.05 remained in the final model. To look to the final model fitness, Hosmer and Lemeshow goodness-of-fit test was used [15]. Multicollinearity among independent variables was also assessed using variance inflation factor (VIF).

Results

In our study, the minimum dietary diversity was 14.9% which is slightly higher than the EDHS report of 13.8%. Since Ethiopia is one of the developing countries where most of mothers living in rural areas, majority (88.35%) of our respondents were living in there. Majority of the children born were female 1575 (53.03%) and aged between 12 and 17 months (36.73%). Most of mothers (52.25%) aged between 25 and 34 years old and those who have not get into any formal education took the majority (62.02%). Most of mothers (57.43%) have not directly engaged in income generating occupations. But, agricultural works remained highly prevalent work among mothers (21.60%) and fathers (61.47%) of children aged 6–23 months. The current study has revealed that mother’s exposure to mass media was low. From the interviewed mothers 1.77% reads newspaper, 13.73% listen to radio and 9.03% watches television at least once in a week. Most (57.05%) of Ethiopian mothers of children aged 6–23 months provide complementary feeding using improved water sources, and also majority of mothers were living below the middle level of household wealth index. Majority of the respondents (66.3%) waits more than 2 years to give birth to their living youngest child. Ethiopia still has a work to do in institutional delivery because around 62% of delivery was conducted in home. Almost one-third of mothers gave birth to child without having any antenatal care visit in the health institution. Besides, post-natal check-up within 2 months after delivery was not conducted for majority (88.43%) of mothers. Table 1 has shown different individual, parental, household, healthcare and community-level characteristics of last children who are living with their mother and aged between 6 and 23 months.
Table 1

Individual, parental, household, healthcare and community-level characteristics of living children aged between 6 and 23 months, Ethiopia, 2016

Characteristics

n

%

Child characteristics

Sex of child

 Male

1396

46.97

 Female

1576

53.03

Age of child (months)

 6–11

1044

35.14

 12–17

1091

36.73

 19–23

836

28.13

Birth order

 Firstborn

547

18.4

 Second to fourth

1284

43.2

 Five or more

1141

38.4

Diarrheaa

 No

2394

80.54

 Yes

573

19.28

Cough

  

 No

2267

76.29

 Yes

705

23.71

Parental characteristics

Mother’s age (years)

 15–24

805

27.08

 25–34

1553

52.25

 35–49

614

20.67

Mother’s education

 No education

1844

62.02

 Primary education

904

30.40

 Secondary and higher

225

7.58

Mother’s occupation

 Not working

1707

57.43

 Non agricultural works

590

19.84

 Agricultural works

642

21.60

 Others

33

1.13

Mother’s literacy

 Cannot read at all

2203

74.11

 Able to read only parts of sentence

356

11.98

 Able to read whole sentence

413

13.91

Mother’s marital status

 Currently married

2838

95.49

 Formerly married

134

4.51

Reads newspaper or magazine

 Not at all

2777

93.45

 Less than once a week

142

4.78

 At least once a week

53

1.77

Listen to radio

  

 Not at all

2177

73.25

 Less than once a week

387

13.02

 At least once a week

408

13.73

Watches television

 Not at all

2446

82.27

 Less than once a week

258

8.70

 At least once a week

268

9.03

Father’s education

 No education

1254

42.18

 Primary

1177

39.62

 Secondary and higher

385

12.96

 Don’t know and missing

136

5.26

Father’s occupation

 Not working

219

7.38

 Non agricultural works

678

22.82

 Agricultural works

1827

61.47

 Others and missing

248

8.33

House hold characteristics

Source of drinking water

 Improved

1696

57.05

 Un improved

1276

42.95

Household wealth index

 Poorest

 Poorer

627

21.09

 Middle

666

22.41

 Richer

544

18.31

 Richest

434

14.61

Healthcare characteristics

Preceding birth interval

 No preceding birth

549

18.5

  < 24 months

451

15.2

  ≥ 24 months

1972

66.3

Antenatal care visit

 None

1002

33.71

 1–3 times

870

29.28

 4 and above

987

33.21

I don’t know and missing

113

3.80

Mode of delivery

 Non-Cesarean section

2897

97.48

 Cesarean section

75

2.52

Place of delivery

 Home

1845

62.05

 Health facility

1068

35.95

 Other

59

2.00

Post-natal check-up within 2 months

 No

2628

88.43

 Yes

232

7.79

 I don’t know and missing

112

3.78

Community-level factors

Residence

 Urban

346

11.65

 Rural

2626

88.35

Minimum dietary diversity

 Adequate minimum dietary diversity

443

14.9

 Inadequate minimum dietary diversity

2529

85.1

Total

2972

 

aFor having diarrhea recently 5 respondents responded “I don’t know”

Minimum dietary diversity rate among children aged 6–23 months was also described with their current breastfeeding status. There was high rate of MDD among breastfeeding children in the all age classification [(6–11 months), (12–17 months), (18–23 months)]. Among breastfed children who attained MDD, majority of them were in the age group of 6–11 months next in 18–23 months which accounts 9.6% and 7.25%, respectively. The least (5.8%) were in 12–17 months age group. From those children who attained the MDD and not breastfeeding, majority rate (5.5%) was from the age group of 18–23 months. The least MDD rate was scored among children aged 6–11 months who were not breastfeeding during the interview (Table 2).
Table 2

Types of foods given to children aged 6–23 months a day before the interview, EDHS, 2016

Food groups

Age of a child (months)

N

6–11

12–17

18–23

n

%

n

%

n

%

Grain, roots and tubers

519

28

734

39.7

596

32.3

1849

Legumes and nuts

186

30

233

38

194

32

613

Dairy products

403

35.4

411

36.1

324

28.5

1138

Flesh foods

46

18.4

122

48.8

82

32.8

250

Eggs

154

31.3

189

38.4

149

30.3

492

Vitamin A-rich fruits and vegetables

206

25.1

346

42.1

269

32.8

822

Other fruits and vegetables

142

28.1

204

40.3

160

31.6

506

Total

1514

 

2239

 

1774

 

5057

By controlling for possible confounders, variables which remained in the final model were frequency of reading to newspaper or magazine, frequency of listening to radio, father’s educational level and household wealth index. Those children whose mothers read to newspaper or magazine at least once in a week had 81% less chance to be inadequate for MDD. Furthermore, statistically significant result has shown that the odds of being inadequate to minimum dietary diversity among children whose mothers read to newspaper or magazine less than once in a week was 56% less likely (AOR = 0.44; 95% CI 0.23, 0.83) than those children’s mother who do not read at all. Likewise, the odds of being inadequate to MDD among children who had mothers that listen to radio at least once in a week was 57% less likely than (AOR = 0.43; 95% CI 0.30, 0.62) those children who had mothers that did not listen at all. Those fathers who had attained primary education had 41% less likely (AOR = 0.59; 95% CI 0.37, 0.94) odds of having children who are inadequate to minimum dietary diversity than fathers who did not go to formal education. The odds of having inadequate minimum dietary diversity among children living in richest household was 60% (AOR = 0.40; 95% CI 0.21, 0.76) less likely than children who were living in poorest household (Table 3).
Table 3

Minimum dietary diversity among children aged between 6 and 23 months, Ethiopia, 2016

Minimum dietary diversity

Sample size

n

%

Minimum dietary diversity, breastfeed (6–11 months)

981

102

9.6

Minimum dietary diversity, non-breastfeed (6–11 months)

63

18

3.5

Minimum dietary diversity, breastfeed (12–17 months)

999

179

5.8

Minimum dietary diversity, non-breastfeed (12–17 months)

93

19

4.9

Minimum dietary diversity, breastfeed (18–23 months)

638

88

7.25

Minimum dietary diversity, non-breastfeed (18–23 months)

198

36

5.5

Based on our criteria of beta coefficient change greater than twenty percent, there was no significant confounder or interaction observed. The significance level of Hosmer–Lemeshow test for goodness of fit was 0.33. Since the probability is greater than 0.05, we fail to reject the null hypothesis and shows that there is no significant difference between the observed and model-predicted values. Therefore, our final model fit the data well. The final model of this study showed that the mean value of VIF was 1.45 which indicated there was no multicollinearity in the final model (Fig. 1).
Fig. 1
Fig. 1

Multicollinearity test for predictors in the final model significantly associated with inadequate minimum dietary diversity of children 6–23 months, EDHS 2016

Discussion

The present study has analyzed the nationally representative data from the 2016 Ethiopia Demographic health survey and reveals the important gaps in meeting the minimum dietary diversity criteria by WHO for children aged 6–23 months. We have found prevalence of minimum dietary diversity rate as 14.9% which is slightly higher than the national EDHS report of 2016 [14]. This can be due to the reason that for analyzing to the factors and to give equal chance for all respondents we have cleaned the data set based on important variables (Table 4).
Table 4

Bivariate and multivariate logistic regression between different level predictors and inadequate minimum dietary diversity of children aged 6–23 months, EDHS 2016

Characteristics

COR

Risk for inadequate minimum dietary diversity

95% (CI)

p value

AOR

95% (CI)

p value

Reads newspaper or magazine

      

< 0.001

Not at all [R]

Less than once a week

0.22

(0.13, 0.38)

0.000

0.44

(0.23, 0.83)

0.012

 

At least once a week

0.07

(0.03, 0.19)

0.000

0.19

(0.07, 0.46)

0.000

 

Listen to radio

      

< 0.001

Not at all [R]

Less than once a week

0.47

(0.29, 0.74)

0.001

0.72

(0.42, 1.24)

0.245

 

At least once a week

0.23

(0.16, 0.33)

0.000

0.43

(0.30, 0.62)

0.000

 

Father’s education

      

< 0.001

No education [R]

Primary

0.46

(0.28, 0.75)

0.002

0.59

(0.37, 0.94)

0.028

 

Secondary and higher

0.25

(0.15, 0.40)

0.002

0.62

(0.36, 1.09)

0.102

 

Household wealth index

      

< 0.001

Poorest [R]

Poorer

0.58

(0.31, 1.06)

0.081

0.66

(0.37, 1.17)

0.156

 

Middle

0.56

(0.31, 1.02)

0.059

0.79

(0.44, 1.41)

0.433

 

Richer

0.41

(0.22, 0.75)

0.004

0.69

(0.38, 1.27)

0.240

 

Richest

0.16

(0.08, 0.29)

0.000

0.40

(0.21, 0.76)

0.005

 

One of the factors that the current study has identified is the impact of mother’s access to mass media. Those mothers who read newspaper or magazine at least once in a week have low chance to be inadequate in meeting minimum dietary diversity of their young infant. This finding is concurrent with the study conducted in Nepal and India [16, 17]. Besides, mothers who listen to a radio within a week are also able to feed different food groups to their child and meet the minimum dietary diversity intake. Listening to radio is found a significantly affecting factor in an Indian study conducted using secondary analysis of the national family health survey [17]. Another study conducted in North West Ethiopia and Bangladesh also came up with the same finding that shows mother’s exposure to mass media remains positively associated with improving minimum dietary diversity of children [18, 19].

Being richest in household wealth index has been shown negatively associated with inadequate minimum dietary diversity of a child. Similarly, household wealth was found as predictor of minimum dietary diversity in the four South Asian countries where variable is available, indicating the important role of household resources in determining complementary feeding of children [9]. In our study, especially children who were living in a richest household had significantly less chance to be inadequate in meeting the recommended minimum dietary diversity. This was in line with other study conducted in Ethiopia using the 2011 DHS [20].

Moreover, in the present study education level of fathers has been assessed and became statistically associated with meeting the recommended diversity of food. Compared to no education, as the education level of the fathers increased, the children were more likely to get the recommended minimum dietary diversity. The same finding was also found in Nepalese study [21]. This shows that educated fathers can understand the education message that they got from different mass media like radio or newspaper which more likely enable them to be engaged in achieving their children to the minimum dietary diversity. Since EDHS is using cross-sectional study design, the limitations of this study were causal inferences between associated factors and inadequate MDD cannot be made.

Conclusion

The study revealed different predictors that were significantly associated with the selected WHO recommended complementary feeding practice indicator (minimum dietary diversity). After lots of variables have been assessed significantly, associated factors were: reading frequency of newsletter or magazine, listening frequency to radio, father’s educational level and household wealth index. Minimum dietary diversity is still low in Ethiopia, and the most common food groups consumed were dairy products and grain, roots and tubers. This shows the gap that mothers feed their child the most and easy accessible food rather than of diverse food. This study also came up with the result that increment in the household wealth had a good impact to feed the child to the diverse food groups for better growth and development. By increasing the accessibility, awareness creation using radio, newspaper or magazine was one of the significant game changer methods to improve the inappropriate complementary feeding practice.

Since increasing dietary diversity at the national level is an effective measure to childhood malnutrition reduction and improving the nutritional status of children [8, 22], this study suggests the possible targets of future interventions to improve minimum dietary diversity in Ethiopia. National governments should build the capacity of small-scale producers, particularly women, by ensuring access to public services such as infrastructure, financial services, information and training of appropriate feeding practice. National governments must provide access to education and strengthen social safety nets to ensure that all members of society have income security and can access essential foods and health care. International or local donors should play their pivotal role by funding efforts to achieve the SDGs.

Abbreviations

AOR: 

adjusted odds ratio

CI: 

confidence interval

COR: 

crude odds ratio

DHS: 

demographic health survey

EAs: 

enumeration areas

EDHS: 

Ethiopia demographic health survey

MDD: 

minimum dietary diversity

PSNP: 

Productive Safety Net Program

SDGs: 

Sustainable Development Goals

SVY: 

survey

WHO: 

World Health Organization

VIF: 

variance inflation factor

Declarations

Authors’ contributions

TE conceived the study, designed, wrote the paper, conducted data analysis, drafted and finalized the manuscript for publication. GK, YB, AM and TM assisted with critical reviewing papers. All authors read and approved the final manuscript.

Acknowledgements

We would like to thank the DHS program who let us to access the EDHS data set.

Competing interests

The authors declare that they have no competing interests.

Availability of data and materials

Supporting data for the current study are available from the corresponding author on reasonable request. The EDHS data set was retrieved from https://dhsprogram.com/data/available-datasets.cfm.

Consent for publication

Not applicable.

Ethics approval and consent to participate

Secondary analysis of the data is conducted through ethical way of accessing to DHS data. First and foremost, online request to access the data set was sent to the CSA or ORC Macro (Demographic and Health Survey) and we have been authorized to download data from the Demographic and Health Surveys (DHS) online archive.

Funding

All the authors dedicated their additional working hours to develop this paper with no specific grant from any funding agency.

Publisher’s Note

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Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

Authors’ Affiliations

(1)
Department of Public Health, College of Medicine and Health Sciences (CMHS), Debre Markos University (DMU), Debre Markos, Ethiopia
(2)
Department of Midwifery, College of Medicine and Health Sciences (CMHS), Debre Markos University (DMU), Debre Markos, Ethiopia
(3)
Department of Midwifery, College of Medicine and Health Sciences (CMHS), Debre Birhan University (DMU), Debre Birhan, Ethiopia

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