Initiation of Breast Milk Expression and Associated Factor Among Mothers of Preterm Neonates Admitted to Neonatal Intensive Care Unit, Amhara Region Comprehensive Specialized Hospitals, Ethiopia 2023: Cross-sectional study

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In preterm neonates, due to poor coordination of the sucking and swallowing reflex with breathing, breast milk expression is the best solution to start feeding. This study assesses the initiation of breast milk expression and associated factors among mothers of preterm neonates admitted to NICUs in the Amhara region and comprehensive specialized hospitals. Methods An institutional-based cross-sectional study was conducted in the Amhara region’s comprehensive specialized hospitals from April 15–May 15, 2023. Maternal interviews and the neonate’s chart review were used to gather data from 401 respondents using systematic random sampling. The collected data was entered, coded, and cleaned into Epi-Data version 4.6.0.2 and analyzed by Stata 14.0 software. In the bivariable logistic regression model, variables that had a p-value < 0.25 were further analyzed in the multivariable logistic regression model, where a p-value < 0.05 with a 95% confidence interval was used to determine the association between the dependent and independent variables. Result late initiation of breast milk expression was 340 (84.79%). Respondents GA < 32 weeks (AOR = 3.59; 95% CI: 1.21, 10.61), getting instruction (AOR = 2.48; 95% CI: 1.06, 5.79), family support (AOR = 2.19; 95% CI: 1.10, 4.36), and importance of mother’s milk (AOR = 2.36; 95% CI: 1.24, 4.47) were the results express factors that negatively impact breast milk expression initiation. Conclusion and recommendation Based on the findings, the initiation of breast milk expression was poor, 15.21% of mothers expressed within the first 6 hours of delivery. In the delivery room, it is better to encourage mothers to express breast milk with in the first 6 hours after delivery who gave preterm birth, especially those < 32 weeks. " } { "@context": "http://schema.org", "@type": "BreadcrumbList", "itemListElement": [ { "@type": "ListItem", "position": "1", "item": { "@id": "https://f1000research.com/", "name": "Home" } }, { "@type": "ListItem", "position": "2", "item": { "@id": "https://f1000research.com/browse/articles", "name": "Browse" } }, { "@type": "ListItem", "position": "3", "item": { "@id": "https://f1000research.com/articles/14-871", "name": "Initiation of Breast Milk Expression and Associated Factor Among Mothers..." } } ] } Home Browse Initiation of Breast Milk Expression and Associated Factor Among Mothers... ALL Metrics - Views Downloads Get PDF Get XML Cite How to cite this article Demissew TN, Azanaw YG, Birhan MA and Techane MA. Initiation of Breast Milk Expression and Associated Factor Among Mothers of Preterm Neonates Admitted to Neonatal Intensive Care Unit, Amhara Region Comprehensive Specialized Hospitals, Ethiopia 2023: Cross-sectional study [version 1; peer review: awaiting peer review] . F1000Research 2025, 14 :871 ( https://doi.org/10.12688/f1000research.168551.1 ) NOTE: If applicable, it is important to ensure the information in square brackets after the title is included in all citations of this article. Close Copy Citation Details Export Export Citation Sciwheel EndNote Ref. Manager Bibtex ProCite Sente EXPORT Select a format first Track Share ▬ ✚ Research Article Initiation of Breast Milk Expression and Associated Factor Among Mothers of Preterm Neonates Admitted to Neonatal Intensive Care Unit, Amhara Region Comprehensive Specialized Hospitals, Ethiopia 2023: Cross-sectional study [version 1; peer review: awaiting peer review] Tigist Nigatu Demissew https://orcid.org/0009-0007-6414-3501 1 , Yalemwork Getahun Azanaw 2 , Marta Adugna Birhan 3 , Masresha Asmare Techane 4 Tigist Nigatu Demissew https://orcid.org/0009-0007-6414-3501 1 , Yalemwork Getahun Azanaw 2 , Marta Adugna Birhan 3 , Masresha Asmare Techane 4 PUBLISHED 04 Sep 2025 Author details Author details 1 Department of Pediatric and Child Health Nursing,, Woldia university, Woldia, Amhara, 400, Ethiopia 2 Department of Surgical Nursing, School of Nursing, university of Gondar, Gondar, Amhara, Ethiopia 3 Department of Neonatal Nursing, School of Nursing, University of Gondar, Gondar, Amhara, Ethiopia 4 Department of Pediatrics and Child Health Nursing, School of Nursing, University of Gondar, Gondar, Amhara, Ethiopia Tigist Nigatu Demissew Roles: Conceptualization, Data Curation, Formal Analysis, Methodology, Software, Validation, Writing – Original Draft Preparation, Writing – Review & Editing Yalemwork Getahun Azanaw Roles: Formal Analysis, Investigation, Methodology, Project Administration, Supervision, Validation, Visualization Marta Adugna Birhan Roles: Conceptualization, Data Curation, Methodology, Software, Supervision, Validation, Visualization, Writing – Original Draft Preparation Masresha Asmare Techane Roles: Conceptualization, Formal Analysis, Project Administration, Supervision, Validation, Visualization OPEN PEER REVIEW REVIEWER STATUS AWAITING PEER REVIEW This article is included in the Global Public Health gateway. Abstract Background The initiation of breast milk expression was when mothers began expressing their breast milk. In preterm neonates, due to poor coordination of the sucking and swallowing reflex with breathing, breast milk expression is the best solution to start feeding. This study assesses the initiation of breast milk expression and associated factors among mothers of preterm neonates admitted to NICUs in the Amhara region and comprehensive specialized hospitals. Methods An institutional-based cross-sectional study was conducted in the Amhara region’s comprehensive specialized hospitals from April 15–May 15, 2023. Maternal interviews and the neonate’s chart review were used to gather data from 401 respondents using systematic random sampling. The collected data was entered, coded, and cleaned into Epi-Data version 4.6.0.2 and analyzed by Stata 14.0 software. In the bivariable logistic regression model, variables that had a p-value < 0.25 were further analyzed in the multivariable logistic regression model, where a p-value < 0.05 with a 95% confidence interval was used to determine the association between the dependent and independent variables. Result late initiation of breast milk expression was 340 (84.79%). Respondents GA < 32 weeks (AOR = 3.59; 95% CI: 1.21, 10.61), getting instruction (AOR = 2.48; 95% CI: 1.06, 5.79), family support (AOR = 2.19; 95% CI: 1.10, 4.36), and importance of mother’s milk (AOR = 2.36; 95% CI: 1.24, 4.47) were the results express factors that negatively impact breast milk expression initiation. Conclusion and recommendation Based on the findings, the initiation of breast milk expression was poor, 15.21% of mothers expressed within the first 6 hours of delivery. In the delivery room, it is better to encourage mothers to express breast milk with in the first 6 hours after delivery who gave preterm birth, especially those < 32 weeks. READ ALL READ LESS Keywords associated factor, breast milk, expression, initiation, and neonate. Corresponding Author(s) Tigist Nigatu Demissew ( [email protected] ) Close Corresponding author: Tigist Nigatu Demissew Competing interests: No competing interests were disclosed. Grant information: The University of Gondar has funded this work, but there is no funding for the publication process. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. Copyright: © 2025 Demissew TN et al . This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. How to cite: Demissew TN, Azanaw YG, Birhan MA and Techane MA. Initiation of Breast Milk Expression and Associated Factor Among Mothers of Preterm Neonates Admitted to Neonatal Intensive Care Unit, Amhara Region Comprehensive Specialized Hospitals, Ethiopia 2023: Cross-sectional study [version 1; peer review: awaiting peer review] . F1000Research 2025, 14 :871 ( https://doi.org/10.12688/f1000research.168551.1 ) First published: 04 Sep 2025, 14 :871 ( https://doi.org/10.12688/f1000research.168551.1 ) Latest published: 04 Sep 2025, 14 :871 ( https://doi.org/10.12688/f1000research.168551.1 ) Introduction The initiation of breast milk expression was when mothers began expressing milk from their breasts. 1 The World Health Organization (WHO) advises mothers to breastfeed their newborns during their first life hour. 2 In preterm neonates, sucking and swallowing reflex coordination with breathing is poor, and breast milk expression is the solution to start feeding. 1 , 3 Early initiation of breast milk expression plays a similar role as early initiation of breastfeeding. 1 , 4 – 10 Breast milk is the best form of milk for premature neonates; it reduces complications, improves long-term health, and improves neurodevelopmental outcomes. 11 – 15 Studies in Finland, Australia, and Florida suggest that early initiation of breast milk expression within the first six hours following delivery is key to the long-term success of providing breast milk and is recommended as a strategy to increase milk production. 7 , 16 – 18 Initiating milk expression after the first 6 hours following delivery was found to be related to an increased likelihood of being formula-fed, according to a study in Milan, Italy. 19 According to WHO estimates, failure to follow the best practices for newborn breastfeeding results in more than 800,000 neonatal deaths worldwide each year. 20 Breastfeeding could reduce 20% to 22% of infant fatalities, according to recent studies from Ethiopia, Ghana, Bolivia, and Madagascar. 21 In Ethiopia, preterm birth complications were the first cause of neonatal mortality, it accounts for 37% of the total neonatal deaths, and premature neonates die 1.3 times more than term neonates. 1 , 22 Breast milk reduces morbidity and mortality and supports optimal growth, development, and the overall outcome of the preterm neonate. 4 , 17 , 23 – 28 Preterm neonates have increased impacts on short- and long-term negative outcomes due to delaying breast milk feedings, such as sepsis and necrotizing enterocolitis (NEC), hypoglycemia, weight loss, jaundice, neurodevelopmental delays, morbidity, and mortality. 29 , 30 Initiation of breast milk expression is affected by different factors, including mode of delivery (CS), gestational hypertension, gestational age, a high risk of necrotizing enterocolitis, respiratory distress syndrome, and patent ductus arteriosus. 1 , 31 , 32 WHO recommends a universal target coverage of 90% for exclusive breastfeeding to prevent 13-15% of the 9 million under-five deaths per year in middle- and low-income countries. 33 However, the survival, health growth, and neurodevelopment of preterm newborns remain a problem in many countries despite significant advancements over the previous ten years. 2 According to a study on the breastfeeding experiences of mothers of preterm neonates, expressing milk and breastfeeding are seen as ways to strengthen the development of motherhood and build a stronger bond with their child. 19 A previous study in Ethiopia shows that all respondents were late to initiate breast milk expression. 6 , 34 In the Amhara region, there is limited study, and early breast milk expression is crucial to the management of preterm neonates. Identifying factors promoting ideal breastfeeding practices facilitates efforts to decrease preterm deaths. However little concern was given to the early initiation of breast milk expression. This study aimed to assess the initiation of breast milk expression and associated factors among mothers of preterm neonates admitted to NICUs in the Amhara region. Objectives General objective • To assess the Initiation of breast milk expression and associated factors among mothers of preterm neonates admitted to the Neonatal intensive care unit, at Amhara region comprehensive specialized Hospitals, Ethiopia 2023. Specific objective • To determine the Initiation of breast milk expression among mothers of preterm neonates admitted to the Neonatal intensive care unit, at Amhara region comprehensive specialized Hospitals, Ethiopia 2023. • To assess factors associated with the Initiation of breast milk expression among mothers of preterm neonates admitted to the Neonatal intensive care unit at Amhara region, comprehensive specialized Hospitals, Ethiopia 2023. Methods Study design, period, and area A multicenter institutional-based cross-sectional study was conducted from April 15 to May 15, 2023, in the Amhara region. The study was conducted in eight comprehensive specialized hospitals (University of Gondar, Felege-Hiwot, Tibebe-Ghion, Debre-Markos, Dessie, Deberetabor, Debreibrhan, and Woldya). Those hospitals have special units, like the NICU, and the major services in the NICU include general neonatal care services, routine prescription of a complete blood count, blood exchange transfusion, phototherapy, and ventilation support. Population Source population The source population was all mothers with their preterm neonates who were admitted to the NICU of the Amhara Region Comprehensive Specialized Hospitals. Study population The study population was all mothers with their preterm neonates who were admitted to the NICU at Amhara Region Comprehensive Specialized Hospitals during the study period. Inclusion criteria All mothers with their preterm neonates who were admitted to the NICU of the Amhara Region Comprehensive Specialized Hospitals during the study period. Exclusion criteria The presence of medical contraindications for breastfeeding, neonates keeping NPO, and neonates with incomplete charts during the data collection period was excluded from the study. Sample size determination and sampling procedure The sample size was determined using the single population proportion formula by considering the following assumptions: p = 50% (proportion of mothers with initiation of breast milk expression), 95% confidence interval (Z = 1.96), 5% level of significance, and 5% margin of error (d = 0.05). n = ( Z ) 2 ∗ ( p ∗ 1 − p ) / d 2 n = ( Z ) 2 ∗ ( p ∗ 1 − p ) / d 2 , n = ( 1.96 ) 2 ∗ 0.5 ( 1 − 0.5 ) / ( 0.05 ) 2 = 384 By adding 10% non-respondents (by considering refusal and incomplete charts) the final sample size was estimated to be 422. To ensure the adequacy of sample size, Epi-info version 7.2.3 is used to calculate sample size for factors associated with the initiation of breast milk expression by using 2 factors Gestational age and getting instruction from NICU staff. By using frequency of non-exposed groups and depends on their AOR. Table 1. Sample size determination by considering factors of Initiation of breast milk expression among mothers of preterm. Variables P1 Power CI AOR Sample size GA < 32 weeks 63.7 80% 95% 2.39 238 Get instruction from NICU staff 68.5 80% 95% 0.55 404 As compared with the sample size above the sample size for this study is the largest one in the first objective single population proportion formula which is 422. The allocation of the sample to each hospital was made based on the average number of neonate admissions per month. The overall sample was taken proportionally from each hospital, and a systematic random sampling technique (sampling interval ≈ 2) was used to select the sample participants. Study variables and their measurements Outcome variable: Initiation of breast milk expression was the outcome variable; it is the time when mothers began expressing milk from their breasts, which was measured by asking the mother when she started milk expression. Independent variables Socio-demographic characteristics of the mother: 5 factors (maternal age, educational status, occupational status, marital status and residence). Obstetric and maternal characteristics: 11 factors (Knowing the importance of breast milk for preterm neonate, getting instruction to express breast milk from NICU staff within 6 hours after delivery, Pregnancy-related complications, knowing the benefits of colostrum, Know the importance of mother’s milk over other (powder, cow) milk, mode of delivery, parity, ANC follow-up, place of delivery, Previous NICU experience with preterm admission and Previous milk expression experience for the preterm neonate). Neonatal characteristics: 8 factors (GA, gender, birth weight, postnatal first milk-feeding time, method of feeding, can able to suck a neonate, health status of a neonate and post-natal age). Psychological factors: 4 factors (Support from family members, separation from their premature infants and worried about the amount of milk and kangaroo mother care) were the independent variables. Operational definitions Family support is any support given: food, support in daily living activities, starting from the time she gives birth (husband, mother, sister). 1 , 6 LBW: (low birth weight) <2500 mg, VLBW : (very low birth weight) 1000 – 1500 gm, 1 , 35 Gestational age: this is the time counted in weeks from the first day of the woman’s last menstrual period to the date of delivery. 1 , 36 Preterm birth: It is the birth of a baby 28 weeks GA. 1 , 35 Initiation of breast milk expression: It is time for the mother to begin expressing breast milk, and the mother can begin expressing breast milk usually immediately following childbirth. 3 , 35 Early initiation of breast milk expression : Expression of breast Early within 6 hours of birth 6 – 8 Late initiation of breast milk expression: expression of breast milk > 6 hrs of delivery. 6 , 7 Stable conditions where a neonate has stable vital signs. 37 Fair Vital signs are stable and within normal limits. the neonate is conscious but may be uncomfortable and the neonate needs regular follow-up. 37 Critical Vital signs are unstable and not within normal limits. the neonate may be unconscious. Indicators are unfavorable and the neonate needs strict follow-up. 37 Early neonatal period : this is a period from birth to 7 completed days of life. 1 Late neonatal period : A period from 8 to 28 completed days of life. 1 Early preterm : gestational age 28 weeks, Moderate preterm : gestational age 32 – 34 weeks, Late preterm : >36 weeks. 1 , 38 Incomplete chart: Charts with one of the following factors are missed (gestational age, birth weight, feeding time and neonatal age). Data collection tool The data were collected using interviewer-administered and neonate chart review through structured and validated questionnaires that were adapted from a questionnaire developed from previous studies. 6 , 19 , 24 – 26 , 30 , 31 , 34 , 39 To ensure consistency and accuracy, the data collection instrument was written in English, translated into the local language (Amharic) by a language expert, and then back into English. A 5% 21 pretest was conducted. During pretesting the tool was checked for its consistency. The internal consistency was checked by computing Cronbach’s α with the value of 0.82% from the pretest data. Onsite training was given to data collectors and supervisors before the beginning of data collection. The data was collected by nurses who have previous experience in the NICU and data collection. The completeness of the collected data was checked onsite daily during data collection and received prompt feedback from the supervisor and the principal investigator. All completed data collection forms were examined for completeness and consistency during data management, storage, cleaning, and analysis. Before data collection assent was obtained from the mother then, written consent was obtained after explaining all the purpose, benefits and confidentiality of the information. Data processing and analysis The collected data were entered and coded into Epi-Data version 4.6.0.2 and exported into Stata 16.0 software for analysis. Descriptive statistics were carried out using the mean, frequency, percentage, tables, and figures to present the findings. A box plot was used to check the normality of the continuous data. The outcome variable was dichotomized and coded as 0 and 1, representing those late in initiation of breast milk expression and early in initiation of breast milk expression, respectively. The data was checked for consistency. Descriptive statistics were used to identify the distributions of socio-demographic characteristics among study respondents. Frequencies and cross-tabulations were computed before regression analysis. Multicollinearity was checked by using variance inflation factors (VIF 1.02–1.57, mean VIF = 1.20), and the model goodness of fit test was checked by Hosmer and Lem show goodness of fit tests (p = 0.63). A bivariable logistic regression was conducted to see the relation between the dependent and independent variables of initiation of breast milk expression using a p-value < 0.25. Multivariable logistic regressions at p-value < 0.05 with a 95% confidence interval of the odds ratio were used to determine a statistically significant association. Results Out of 422 participants, 401 (95.02%) were involved in the study. Socio-demographic characteristics Among the study respondents, the age range of respondents was 16–42, and the mean age was 28.86 ± 6.77 SD. More than half of the 245 (61.10%) respondents lived in urban areas. Regarding marital status, 338 (84.29%) respondents were married. Table 2. Socio-demographic characteristics on the Initiation of breast milk expression among mothers of preterm neonate. Variable Frequency (N = 401) Percent (%) Age 35 97 24.19 Residence Rural 156 38.90 Urban 245 61.10 Marital status Married 338 84.29 Single 27 6.73 Widowed, divorced, separated 36 8.98 Educational status Unable to read and write 105 26.18 Primary school 98 24.44 Secondary school 92 22.94 Diploma and above 106 26.43 Occupational status Housewife 187 46.63 Governmental employer 65 16.21 Student 21 5.24 Private employer 53 13.22 Daily laborer 29 7.23 Merchant 46 11.47 Maternal and obstetric characteristics Out of 401 respondents, 236 (58.85%) were Multi para. And 347 (85.79%) have ANC follow-ups; 119 (29.68%) of them have had 4 or more visits. Regarding pregnancy complications, 150 (37.41%) have pregnancy complications. 289 (72.07%) mothers knew the importance of mother’s milk over other (powder, cow) milk. Table 3. Obstetric and maternal factors on the Initiation of breast milk expression among mothers of preterm neonate. Variable Frequency Percent (%) Parity Prime para 126 31.42 Multi para 236 58.85 Grand multi para 39 9.73 ANC follow-up (private or governmental health institution) No 57 14.21 1 time 35 8.73 2 times 74 18.45 3 times 116 28.93 4 and above 119 29.68 Pregnancy-related complications No pregnancy complication 251 62.59 Pregnancy-induced hypertension 87 21.70 Gestational Debits Miletus 10 2.49 Other (APH, malaria, chorioamnionitis, PROM) 53 13.21 Place of delivery Hospital| 245 61.10 Health Center 123 30.67 Home 33 8.23 Mode of delivery SVD 270 67.33 CS delivery 120 29.93 Instrument assisted delivery 11 2.74 Previous NICU experience with preterm admission Yes 51 12.72 No 350 87.28 Previous milk expression experience for the preterm neonate Yes 44 10.97 No 357 89.03 Know the importance of colostrum (first milk) Yes 134 33.42 No 267 66.58 Know the importance of mother’s milk over other (powder, cow) milk Yes 289 72.07 No 112 27.93 Know the importance of mother’s milk for the preterm neonate Yes 182 45.39 No 219 54.61 Get instruction to express breast milk within 6 hours of delivery, from NICU staff Yes 296 73.8 No 105 26.1 When do you express breast milk (outcome variable) Birth - 6 hours 61 15.21 >6 hours 340 84.79 Neonatal factors Among 401 neonates 217 (54.11%) were female and 184 (45.89%) were male neonates. Regarding birth weight, there were 249 (62.09%) LBWT and 152 (37.91%) VLBWT, and the mean birth weight of neonates was 1557.73 with ± 303.23 SD, and the minimum and maximum birth weights were 1000 g and 2200 g, respectively. Table 4. Neonatal characteristics on the Initiation of breast milk expression among mothers of preterm neonate. Variable Frequency Percent (%) Gender Male 184 45.89 Female 217 54.11 Gestational age (GA) <32 weeks (Early preterm) 132 32.92 32-34 weeks (Moderate preterm) 111 27.68 34-36 +6 weeks (Late preterm) 158 39.40 Birth weight 1000 – 1499 (VLBWT) 152 37.91 1500 – 2499 (LBWT) 249 62.09 Post-natal feeding time Birth - 6 hours 59 14.71 >6 hours 342 85.29 Can ably Suck neonate Yes 140 34.91 No 261 65.09 Method of feeding Directly breastfeed 87 21.70 NG tube 204 50.87 Bottle 77 19.20 Other (Cup, Syringe) feeding 33 8. 23 Post-natal age of the neonate Early neonatal period 185 46.13 Late neonatal period 216 53.87 Health status of the neonate Stable 161 40.65 Fair 154 153 Critical 86 21.20 Psychological factors Psychological factors Out of 401 participants, 236 (58.85%) got family support during breast milk expression and 109 (27.18%) are worried about the amount of milk to express milk the first time. Table 5. Psychological factors on the Initiation of breast milk expression among mothers of preterm neonate admitted. Variable Frequency Percent (%) Family support during the expression of breast milk Yes 236 58.85 No 165 41.15 Worry about the amount of milk to express milk the first time Yes 109 27.18 No 292 72.82 KMC (kangaroo mother care) Yes 195 48.63 No 206 51.37 Feeling about separation from neonate Yes 42 10.47 No 359 89.53 Initiation of breast milk expression Out of 401 participants, 340 (84.79%) with [95% CI (80.91, 87.99)] were late initiation of breast milk expression (expressed after 6 hours of delivery) and 15.21% (61) with [95% CI (12.00,19.08)] were early initiation of breast milk expression (expressed within 6 hours of delivery). Figure 1. Initiation of breast milk expression among mothers of preterm neonates admitted at NICU, Amhara region. Factors associated with initiation of breast milk expression On bivariable analysis, eleven (maternal age, get instruction to express breast milk within 6 hours of delivery, from NICU staff, Birth weight, Gestational Age, method of feeding, can able to suck a neonate, postnatal age, know the benefit of colostrum, know the benefit of mother’s milk for preterm neonate, family support and health condition of neonates) variables that have a p-value less than 0.25 was taken as a candidate for multivariable logistic regression analysis. In multivariable logistic regression analysis, mothers who did not get instruction within the first 6 hours after delivery, mothers who did not know the importance of mother’s milk for preterm neonates, mothers who did not get family support, and GA < 32 weeks had p-value < 0.05 with a 95% confidence interval of the odds ratio were the results express factors that negatively impact breast milk expression initiation. Respondents (neonates) with GA 34 weeks (AOR = 3.59; 95% CI: 1.21, 10.61). The other factor identified was that respondents who did not get instruction within the first 6 hours of delivery to express milk from NICU staff were 2.48 times late to initiate breast milk expression as compared with those who got instruction within the first 6 hours of delivery (AOR = 2.48; 95% CI: 1.06, 5.79). Similarly, respondents who did not get family support were 2.19 times late to initiate breast milk expression as compared with those who got family support (AOR = 2.19; 95% CI: 1.10, 4.36). Finally, respondents who do not know the importance of mother’s milk for preterm neonates were 2.36 times late to initiate breast milk expression as compared with those who know the importance of mother’s milk for preterm neonates (AOR = 2.36; 95% CI: 1.24, 4.47). Table 6. Multivariable analysis of factors associated with the Initiation of breast milk expression among mothers of preterm neonate. Variables Late initiation Early initiation COR (95% CI) AOR (95% CI) P value Age 35 85 (25.00) 12 (19.67) 2.11 (0. 96,4.63) 1.68(0.70,4.06) 0.24 Get instruction to express breast milk within 6 hours of delivery, from NICU staff Yes 243 (73.82) 53 (86.89) 1 1 No 97 (28.53) 8 (13.11) 2.64(1.21,5.76) 2.48(1.06,5.79) 0.03** Know the importance of colostrum Yes 108 (31.76) 26 (42.62) 1 1 No 232 (68.24) 35 (57.38) 1.59(0.91,2.78) 1.59(0.84,3.01) 0.14 Know the importance of Breast milk for the preterm neonate Yes 141 (41.47) 41 (67.21) 1 1 No 199 (58.53) 20 (32.79) 2.89 (1.62,5.14) 2.36(1.24,4.47) 0.00** Gestational age in weeks >34 weeks 119 (35.00) 39 (63.93) 1 1 32-34 weeks 95 (27.94) 16 (26.23) 1.94 (1.02,3.69) 1.99(0.97,4.07) 0.058 < 32 weeks 126 (37.06) 6 (9.84) 6.88(2.81,16.84) 3,59(1.21,10.61) 0.02** Birth weight LBWT 196 (57.65) 53 (86.89) 1 1 VLBWT 144 (42.35) 8 (13.11) 4.86(2.24,10.55) 1.98(0.76,5.13) 0.15 Can a neonate able to suck Yes 109 (32.06) 31 (50.82) 1 1 No 231 (67.94) 30 (49.18) 2.18 (1.26,3.80) 0.64(0.25,1.63) 0.35 Method of feeding Breastfeed 63 (18.53) 24 (39.34) 1 1 NG tube 182 (53.53) 22 (36.07) 3.15(1.65, 6.01) 2.26(0.78,6.51) 0.13 Bottle 65 (19.12) 12 (19.67) 2.06 (0.95,4.47) 1.80(0.65,4.95) 0.25 Other (cup, syringe) 30(8.82) 3(4.92) 3.80(1.06,13.65) 1.55(0.33,7.25) 1.55 Postnatal age Birth-7days 145 (42.65) 40 (65.57) 1 1 8 – 28 days 195 (57.35) 21 (34.43) 2.56(1.44,4.53) 0.59(0.30,1.14) 0.11 Health status of the neonate Stable 126 (37.06) 35 (57.38) 1 1 Fair 134 (39.41) 20 (32.79) 1.86(1.02,3.39) 1.15(0.55,2.41) 0.70 Critical 80 (23.53) 6 (9.84) 3.70 (1.49,9.20) 2.15(0.74,6.19) 0.15 Family support Yes 191 (56.18) 45 (73.77) 1 1 No 149 (43.82) 16 (26.23) 2.19 (1.19,4.03) 2.19(1.10,4.36) 0.02** Discussions In this study, the late initiation of breast milk expression, 340 (84.79%) were expressed breast milk after 6 hours of delivery. Which was higher than studies conducted in Finland, Germany, England, and Australia (64%, 58.6%, 32%, and 15%, respectively). 7 , 30 , 40 , 41 This discrepancy could be the result of differences in the nation’s level of development, the concern of health professionals regarding milk expression and strategies for the care of premature newborns, and differences in study design. In Germany, the study was conducted using the survey method, and in Australia, the study was conducted using a systematic review study design. However, the current study findings were slightly lower than reported in Addis Ababa. 7 These disparities are likely due to differences in the study population, sample size, and study area. This might lead to a variation. This finding revealed that the odds of neonates who had GA 34 weeks (AOR = 3.59; 95% CI: (1.21, 10.61). This finding was supported by previous studies. 6 , 24 , 30 , 31 , 39 The possible explanations are that newborns < 32 weeks GA need orogastric or NG tube feeding, which should start within 24 hours of birth, depending on the clinical condition. 1 , 2 , 42 Due to this reason instructing mothers to express milk might be based on the neonates’ clinical condition. The odds of mothers who do not get instruction within the first 6 hours of delivery to express milk from NICU staff were 2.48 times late to initiate breast milk expression as compared with those who got instruction within the first 6 hours of delivery (AOR = 2.48; 95% CI: 1.06, 5.79). This finding was supported by studies conducted in Ethiopia. 6 Prematurity is associated with acute or chronic maternal illness and obstetric factors. 1 Mothers are observed in the maternity department for the first six hours following delivery. Due to this reason, it might be too late to advise the woman to express breast milk. 6 Implementation of breast milk information and staff education led to improvements in the milk expression practices of mothers who had preterm neonates. 7 The odds of mothers who do not get family support during breast milk expression were 2.19 times late to initiate breast milk expression as compared with those who got family support during breast milk expression (AOR = 2.19; 95% CI: 1.10, 4.36). This report was supported by previous studies. 20 , 32 As soon as the infants’ and mothers’ conditions permit, parents of newborns in the NICU are given the proper support with milk expression. 43 , 44 A supporter who motivates mothers, emotionally and psychologically to increase milk production. 1 The odds of mothers who do not know the importance of mother’s milk for preterm neonates were 2.36 times more likely late to initiate breast milk expression as compared with those who know the importance of mother’s milk for preterm neonates (AOR = 2.36; 95% CI: 1.24, 4.47). This finding was supported by a previous study. 39 Breast milk is the main dietary source for preterm neonates. The value and significance of human milk for neonates’ health should be explained to mothers. 1 , 2 Limitations of the study Due to the cross-sectional nature of the study, it is difficult to determine the association between outcome and independent variable. Conclusion and recommendations In conclusion, the initiation of breast milk expression was poor; 15.21% of mothers expressed within the first 6 hours of delivery; respondents didn’t get instruction within the first 6 hours of delivery; respondents didn’t know the importance of mother’s milk for preterm neonates; respondents didn’t get family support; and neonates with GA < 32 weeks were significantly associated with late initiation of breast milk expression. In the delivery room, it is better to encourage mothers to express breast milk with in the first 6 hours after delivery, who give preterm birth, especially < 32 weeks. Ethical approval and consent to participate Ethical approval (Ref. No S/N/178/2015) was obtained from the ethical review committee of the institution review board (IBR) of the University of Gondar. A formal latter of administrative approval was obtained from Amhara Public Health Institute for each Hospital. Finally, written consent was obtained from the mothers after explaining all the purpose, benefits, confidentiality of the information, and the voluntary nature of participation in the study before data collection. All methods were carried out in accordance with the declaration of Helsinki and relevant guidelines and regulations. The names, identification number of study participants were not recorded on the data collection tool. All data were kept in strictly confidential and used only for the study purpose. Availability of data and materials figshare: Initiation of breast milk expression and associated factors among mothers of preterm neonates admitted to NICUs in the Amhara region and comprehensive specialized hospitals (data), https://doi.org/10.6084/m9.figshare.29958278.v1 . 45 figshare: ethical clearance, https://doi.org/10.6084/m9.figshare.29958374.v1 . 46 figshare: Questionary, consent and participant information, https://doi.org/10.6084/m9.figshare.29958548.v1 . 47 figshare: table, https://doi.org/10.6084/m9.figshare.29958599.v1 . 48 figshare: STROBE_checklist_combined, https://doi.org/10.6084/m9.figshare.29959181.v1 . 49 figshare: Manuscript, https://doi.org/10.6084/m9.figshare.29959220.v1 . 50 Data are available under the terms of the Creative Commons Attribution 4.0 International license (CC-BY 4.0). Acknowledgment The authors would like to thank the University of Gondar. 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Comments on this article Comments (0) Version 1 VERSION 1 PUBLISHED 04 Sep 2025 ADD YOUR COMMENT Comment Author details Author details 1 Department of Pediatric and Child Health Nursing,, Woldia university, Woldia, Amhara, 400, Ethiopia 2 Department of Surgical Nursing, School of Nursing, university of Gondar, Gondar, Amhara, Ethiopia 3 Department of Neonatal Nursing, School of Nursing, University of Gondar, Gondar, Amhara, Ethiopia 4 Department of Pediatrics and Child Health Nursing, School of Nursing, University of Gondar, Gondar, Amhara, Ethiopia Tigist Nigatu Demissew Roles: Conceptualization, Data Curation, Formal Analysis, Methodology, Software, Validation, Writing – Original Draft Preparation, Writing – Review & Editing Yalemwork Getahun Azanaw Roles: Formal Analysis, Investigation, Methodology, Project Administration, Supervision, Validation, Visualization Marta Adugna Birhan Roles: Conceptualization, Data Curation, Methodology, Software, Supervision, Validation, Visualization, Writing – Original Draft Preparation Masresha Asmare Techane Roles: Conceptualization, Formal Analysis, Project Administration, Supervision, Validation, Visualization Competing interests No competing interests were disclosed. Grant information The University of Gondar has funded this work, but there is no funding for the publication process. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. Article Versions (1) version 1 Published: 04 Sep 2025, 14:871 https://doi.org/10.12688/f1000research.168551.1 Copyright © 2025 Demissew TN et al . This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Download Export To Sciwheel Bibtex EndNote ProCite Ref. Manager (RIS) Sente metrics Views Downloads F1000Research - - PubMed Central info_outline Data from PMC are received and updated monthly. - - Citations open_in_new 0 open_in_new 0 open_in_new SEE MORE DETAILS CITE how to cite this article Demissew TN, Azanaw YG, Birhan MA and Techane MA. Initiation of Breast Milk Expression and Associated Factor Among Mothers of Preterm Neonates Admitted to Neonatal Intensive Care Unit, Amhara Region Comprehensive Specialized Hospitals, Ethiopia 2023: Cross-sectional study [version 1; peer review: awaiting peer review] . F1000Research 2025, 14 :871 ( https://doi.org/10.12688/f1000research.168551.1 ) NOTE: If applicable, it is important to ensure the information in square brackets after the title is included in all citations of this article. COPY CITATION DETAILS track receive updates on this article Track an article to receive email alerts on any updates to this article. TRACK THIS ARTICLE Share Open Peer Review Current Reviewer Status: AWAITING PEER REVIEW AWAITING PEER REVIEW ? 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