title: Measurement of breastfeeding initiation: Ethiopian mothers' perception about survey questions assessing early initiation of breastfeeding.
abstract: 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.
  
  
  CONCLUSIONS
  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.
authors.affiliation: London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, UK.
authors.forename: Mihretab Melesse
authors.initials: MM
authors.lastname: Salasibew
authors.affiliation: London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, UK.
authors.forename: Suzanne
authors.initials: S
authors.lastname: Filteau
authors.affiliation: London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, UK.
authors.forename: Tanya
authors.initials: T
authors.lastname: Marchant
keywords: Breast milk; Breastfeeding; Early initiation; Essential interventions; Infant feeding; Saving newborn lives