Pone 0230978

PLOS ONE
RESEARCH ARTICLE
Associations between infant and young child

feeding practices and acute respiratory
infection and diarrhoea in Ethiopia: A
propensity score matching approach
Kedir Y. Ahmed ID1,2*, Andrew Page2, Amit Arora2,3,4,5, Felix Akpojene Ogbo2,6, Global
Maternal and Child Health Research collaboration (GloMACH)¶
1 College of Medicine and Health Sciences, Samara University, Samara, Ethiopia, 2 Translational Health
a1111111111
Research Institute, Western Sydney University, Campbelltown, NSW, Australia, 3 School of Science and
a1111111111 Health, Western Sydney University, Campbelltown, NSW, Australia, 4 Oral Health Services, Sydney Local
a1111111111 Health District and Sydney Dental Hospital, NSW Health, Sydney, Australia, 5 Discipline of Child and
a1111111111 Adolescent Health, Sydney Medical School, Faculty of Medicine and Health, The University of Sydney,
a1111111111 Sydney, NSW, Australia, 6 General Practice Unit, Prescot Specialist Medical Centre Makurdi, Makurdi,
Benue State, Nigeria
¶ Members of GloMACH are provided in the acknowledgements.

* [email protected]
OPEN ACCESS
Citation: Ahmed KY, Page A, Arora A, Ogbo FA,

Global Maternal and Child Health Research
Abstract
collaboration (GloMACH) (2020) Associations
between infant and young child feeding practices
and acute respiratory infection and diarrhoea in
Background
Ethiopia: A propensity score matching approach. Acute respiratory infection (ARI) and diarrhoea are the leading causes of childhood morbid-
PLoS ONE 15(4): e0230978. https://doi.org/
ity and mortality in Ethiopia. Understanding the associations between infant and young child
10.1371/journal.pone.0230978
feeding (IYCF) and ARI and diarrhoea can inform IYCF policy interventions and advocacy in
Editor: Maria Christine Magnus, Norwegian
Ethiopia. This study aimed to investigate the relationship between IYCF practices and ARI
Institute of Public Health, NORWAY
and diarrhoea in Ethiopian children.
Received: December 3, 2019
Accepted: March 12, 2020 Methods

Published: April 1, 2020 This study used the Ethiopia Demographic and Health Survey (EDHS) data for the years
Peer Review History: PLOS recognizes the 2000 (n = 3680), 2005 (n = 3528), 2011 (n = 4037), and 2016 (n = 3861). The association
benefits of transparency in the peer review between IYCF practices and (i) ARI and (ii) diarrhoea were investigated using propensity
process; therefore, we enable the publication of score matching and multivariable logistic regression models. The IYCF practices include
all of the content of peer review and author
early initiation of breastfeeding, exclusive breastfeeding (EBF), predominant breastfeeding,
responses alongside final, published articles. The
editorial history of this article is available here: introduction of complementary foods, continued breastfeeding at two years and bottle
https://doi.org/10.1371/journal.pone.0230978 feeding.
Copyright: © 2020 Ahmed et al. This is an open
access article distributed under the terms of the Results
Creative Commons Attribution License, which
Infants and young children who were breastfed within 1-hour of birth and those who were
permits unrestricted use, distribution, and
reproduction in any medium, provided the original exclusively breastfed had a lower prevalence of ARI. Infants who were exclusively and pre-
author and source are credited. dominantly breastfed had a lower prevalence of diarrhoea. Early initiation of breastfeeding
Data Availability Statement: The analysis was (Odds ratio [OR]: 0.81; 95% confidence interval [CI]: 0.72, 0.92) and EBF (OR: 0.65; 95%
based on the datasets collected Ethiopian CI: 0.51, 0.83) were associated with lower risk of ARI. Bottle-fed children had higher odds of
PLOS ONE | https://doi.org/10.1371/journal.pone.0230978 April 1, 2020 1 / 20

PLOS ONE Infant and young child feeding practices and acute respiratory infection and diarrhoea in Ethiopia
Demographic Health Survey. Information on the ARI (OR: 1.36; 95% CI: 1.10, 1.68). Early initiation of breastfeeding and EBF were associ-
data and content can be accessed at https:// ated with lower odds of diarrhoea (OR: 0.88; 95% CI: 0.79, 0.94 for Early initiation of breast-
dhsprogram.com/data/available-datasets.cfm. The
authors did not have special access privileges.
feeding and OR: 0.51; 95% CI: 0.39, 0.65 for EBF). Infants who were predominantly
breastfed were less likely to experience diarrhoea (OR: 0.69; 95% CI: 0.53, 0.89).
Funding: This study received no grant from any
funding agency in public, commercial or not for
profit sectors. Conclusion
Competing interests: The authors declare that they The recommended best practices for preventing ARI and diarrhoeal diseases in infants and
have no competing interests. young children namely: the early initiation of breastfeeding, EBF and avoidance of bottle
Abbreviations: ANC, Antenatal Care; ARI, Acute feeding should be institutionalized and scale-up in Ethiopia as part of implementation sci-
Respiratory Infection; OR, Odds Ratio; BFHI, Baby- ence approach to cover the know-do-gaps.
Friendly Hospital Initiative; CI, Confidence Interval;
CSA, Central Statistics Agency; DHS, Demographic
and Health Survey; EA, Enumeration Areas; EBF,
Exclusive Breastfeeding; EIBF, Early Initiation of
Breastfeeding; EDHS, Ethiopian Demographic and
Health Survey; HSTP, Health Sector Introduction
Transformation Plan; ICF, Inner City Fund; IYCF,
Acute respiratory infection (ARI) and diarrhoea are the leading causes of childhood morbidity
Infant and Young Child Feeding; JMP, Joint
Monitoring Program; MDG, Millennium
and mortality globally, particularly in low- and middle-income countries (LMICs) [1–3]. In
Development Goal; NRERC, National Research 2015, ARI and diarrhoea were the first and the fourth leading causes of childhood mortality
Ethics Review Committee; PNC, Postnatal Care; worldwide, attributable to over one million global under-five deaths [1, 2]. Previous studies
PSM, Propensity Score Matching; SMD, have shown that childhood ARI and diarrhoea were associated with adverse health and devel-
Standardized Mean Difference; SDG, Sustainable opmental outcomes [4–8]. ARI and diarrhoea in children have been associated with frequent
Development Goals; SNNPR, Southern Nations
hospital visits and admission [6]. Studies conducted in LMICs have shown that early initiation
Nationalities and Peoples Regions; UNICEF, United
Nation Children’s Fund; USAID, United States of breastfeeding (EIBF) and exclusive breastfeeding (EBF) were protective against diarrhoea
Agency for International Development; USD, United [9–14] and ARI [9, 10].
States Dollar; VIP, Ventilated Improved Pit; WASH, Evidence from sub-Saharan African [11, 13, 15] and Asian [10, 16] countries have indicated
Water, Sanitation and Hygiene; WHO, World Health that inappropriate introduction of complementary foods and bottle feeding were associated
Organization.
with the onset of diarrhoea among infants and young children. This is potentially due to the
replacement of irreplaceable human milk by complementary foods and contamination of the
food and/or teat/nipple of the bottle [17, 18]. Despite the benefits of appropriate breastfeeding,
EIBF and EBF prevalence estimates remain low in LMICs, 42% [19] and 37% [14], respectively.
This suggests that many infants and young children are at increased risk of experiencing ARI
and diarrhoea, and even more likely to die from preventable and treatable diseases like ARI
and diarrhoea [1–3].
Based on the World Bank assessment [20], Ethiopia is a low-income country, with strong
and broad-based economic growth compared to other nations in the Eastern African region.
However, it is one of the poorest countries in Africa, with a per capita income of USD790 per
year [20], indicating that access to key social and health amenities that can help to reduce pre-
ventable child morbidity and mortality are limited. In the past two decades, Ethiopia has seen
substantial reductions in infant mortality (from 97 in 2000 to 43 per 1000 in 2019) and under-
five mortality (from 166 in 2000 to 55 per 1000 in 2019) [21, 22]. Despite these improvements,
one in 15 children still dies before reaching age five years, and 7 out of 10 of these deaths occur
in the first year of birth [21, 23–25]. In these deaths, childhood vaccination and appropriate
IYCF practices could play important roles in preventive strategies; however, recent studies
have indicated that vaccination coverage (43%) [22] and IYCF practices (e.g., EIBF (75.5%)
and EBF at six months (59.9%) [26]) were below the Ethiopian Health Sector Transformation
Plan target of 95%, 90% and 72%, respectively [27]. Additionally, a recent study indicated that
early cessation of EBF was associated with ARI and diarrhoea [32]. Though useful, this study
did not provide relevant evidence for other important IYCF indicators, including EIBF,

predominant breatfeeding and introduction of solid, semi-solid or soft foods. These indicators
have been showed to either act as ‘protective’ or ‘predictive’ factors for both ARI and diarhoea
in LMICs [10, 11, 13].
Understanding and quantifying the relationship between IYCF practices and ARI and diar-
rhoea among infants and young children is crucial to health practitioners and policymakers in
Ethiopia. This information will help in IYCF policy formulation and advocacy, which can, in
turn, play an important role in reducing child morbidity and mortality due to ARI and diar-
rhoea. This assessment is also important in Ethiopia given the current global health efforts–the
United Nation’s Sustainable Development Goals (SDG-3.2: ending preventable deaths of new-
borns and under-five children by 2030) [28] and Global Action Plan for Pneumonia and Diar-
rhoea (GAPPD: ending preventable pneumonia and diarrhoea deaths by 2025) [8].
Accordingly, this study aimed to investigate the associations between IYCF practices and ARI
and diarrhoea in Ethiopian children.
Methods
Data sources
The study used the Ethiopia Demographic and Health Survey (EDHS) data for the years 2000
(n = 3680), 2005 (n = 3528), 2011 (n = 4037), and 2016 (n = 3861). The EDHS used the house-
hold questionnaire to collect information on households, and the women’s questionnaire to
collect information on child health and nutrition. The surveys were implemented by the Ethio-
pia Central Statistical Agency (CSA) and Inner City Fund (ICF) International, and funded by
the United States Agency for International Development, and the Government of Ethiopia
[21, 23–25].
The EDHS used a two-stage stratified cluster sampling technique to select households (the
secondary sampling unit) for inclusion in the survey. In stage one, after the nine administrative
units were stratified into 12 urban and 11 rural strata, Enumeration Areas (EAs) were selected
proportional to the household size of the cluster. In stage two, a fixed number of households
were selected from each EA using the list of households as a sampling frame [21, 23–25]. All
women aged 15–49 years who were permanent residents or visitors in the selected households
the night before the survey were included as respondents. The response rates in the surveys
were high, ranging from 94.6% in 2016 to 97.8% in 2000. Our analyses were restricted to living
children who lived with the respondents to minimize recall bias, consistent with past studies
[11, 15]. A total weighted sample of 15,106 women was used, and additional information on
the surveys methodology is provided elsewhere [21, 23–25].
Study setting
Ethiopia is the second most populous country (with more than 110 million population) in
Africa after Nigeria [29]. The population age structure of Ethiopia is predominantly young
populations with 41.6% under the age of 15 years, and women of reproductive age account for
23.4% of the population [30]. The Ethiopian health service structure follows a three-tier sys-
tem: primary-level health care (health posts, health centres, and primary hospitals), secondary-
level health care (General Hospitals) and tertiary-level health care (teaching and specialized
hospitals) [27].
Outcome variables
The outcome variables were ARI and diarrhoea, measured based on maternal recall of symp-
toms of cough and shortness of breath, and diarrhoea, respectively [31]. ARI was defined as

the occurrence of cough accompanied by short and rapid breathing during the two weeks’
period preceding the survey. Diarrhoea was defined as the passage of three or more loose or
liquid stools per day during the two weeks’ period preceding the survey [31, 32].
Exposure variables
The main exposure variables were IYCF indicators (EIBF, EBF, predominant breastfeeding,
the introduction of complementary foods, continued breastfeeding at two years and bottle
feeding) [33]. IYCF indicators were defined as follows:
• EIBF was defined as the proportion of children aged 0–23 months who commenced breast-
feeding within the first hour of birth.
• EBF was defined as the proportion of infants 0–5 months of age who were fed no other food
or drink, not even water, except breast milk (including milk expressed or from a wet nurse),
but allows the infant to receive oral rehydration salt, drops, and syrups (vitamins, minerals
and medicines).
• Predominant breastfeeding was defined as the proportion of infants 0–5 months of age who
received breast milk (including milk expressed or from a wet nurse) as the predominant
source of nourishment, but allows water, water-based drinks, fruit juice, oral rehydration
solution, drops, or syrups of vitamins and medicines during the previous day.
• Introduction of complementary foods (solid, semi-solid or soft foods) was defined as the
proportion of infants 6–8 months of age who received solid, semi-solid or soft foods in the
previous 24 hours, during the day and at night.
• Continued breastfeeding at two years of age was defined as the proportion of children aged
20–23 months who received breast milk during the previous day.
• Bottle feeding was defined as the proportion of children 0–23 months of age who were fed
any liquid (including breast milk) or semi-solid food from a bottle during the previous day.
Potential confounders
The potential confounders were selected based on previously published studies [10, 13, 15, 26,
34, 35] and data availability. Potential confounding factors were broadly classified into socio-
economic, demographic and behavioural, health service and community-level factors.
Socio-economic factors included mothers’ or fathers’ education, maternal employment and
household wealth status. Demographic and behavioural factors included maternal age, family
size, desire for pregnancy, listening to the radio, reading newspaper/magazine and watching
television. Health service factors included ever use of a vaccine, frequency of antenatal care
(ANC) visits, place of birth, and timing of first postnatal care (PNC) visit. Community-level
factors included a place of residence and region of residence.
The study also considered the type of cooking fuel in the analyses of ARI, and the source of
drinking water and type of toilet facility in the analyses of diarrhoea as potential effect measure
modifiers. This was done to investigate whether the association between IYCF practices and
each outcome differed across each stratum for the type of cooking fuel, source of drinking
water and sanitation level. This approach is consistent with previously published studies from
Africa [13, 15, 36–38]. In the current study, households that used electricity, natural gas, bio-
gas, or kerosene as a cooking fuel were classified as ‘improved’, while those households that
used charcoal, firewood, or dung were grouped as ‘not improved’. This classification was
based on previously published studies conducted in LMICs [39–41].

The source of drinking water and type of toilet facility were classified as ‘improved’ or ‘not
improved’, based on the taxonomy of the WHO and UNICEF Joint Monitoring Programme
(JMP) for Water and Sanitation [42] as applied in past studies [13, 15]. Households that used
piped water, public tap or standpipe, a tube well or borehole, protected well/spring, rainwater
and/or bottled water were classified as ‘improved’. Households that used unprotected well/
spring, tanker truck/cart, surface water, and/or sachet water were grouped as ‘not improved’.
Type of toilet facility was also grouped as ‘improved’ (included flush/pour-flush toilets or
flush/pour-flush toilets piped to the sewer system, septic tank or pit latrine; ventilated
improved pit (VIP) latrine; pit latrine with slab and/or composting toilet). ‘Not improved’ type
of facility included flush/pour-flush not piped to sewer, septic tank or pit latrine; pit latrine
without slab/open pit; bucket or hanging toilet/hanging latrine and no facility/bush/field.
Analytical strategy
The initial analysis involved the tabulation of frequencies and percentages of socioeconomic,
demographic, health-service and community-level factors over the survey years (2000–2016).
Prevalence of ARI and diarrhoea were calculated for each of the exposure variables (i.e., EIBF,
EBF, predominant breastfeeding, the introduction of solid, semi-solid and soft foods, contin-
ued breastfeeding at two years, and bottle feeding). The EDHS data from 2000 to 2016 were
combined to increase the study power and precision of estimates. Before statistical analyses, all
variables were checked for missing properties; nevertheless, there was no evidence of missing-
ness at random.
Propensity score matching (PSM) and multivariable logistic regression were used to investi-
gate the associations between IYCF practices and ARI and diarrhoea. Observational studies
(including cross-sectional surveys) are helpful to investigate the association between exposure
and outcome variables [43]. However, in observational studies, unlike randomized controlled
trials (RCTs), exposure selection depends on the participant’s self-selection in which individu-
als with specific characteristics may be exposed than other participants [43, 44]. This non-ran-
domized self-selection in the exposure can confound the measure of association between the
exposures and the outcomes [43, 45]. To minimise the imbalance in participant characteristics
between exposed and unexposed groups, Rosenbum and Rubin [46] proposed the PSM
approach that takes into account the fundamental differences between the two groups. PSM is
a technique to balance the propensity scores of the exposed and unexposed groups so that
direct comparisons of covariates in both groups are meaningful [46]. Propensity scores are
defined as “the conditional probability of being treated or exposed given the covariates” [47].
The key assumption in propensity score analyses is that participants whose propensity scores
are equivalent have comparable covariate distribution [43]. Additional information on the the-
ories and practices of PSM have been published elsewhere [44, 47–49].
In observational studies, researchers have indicated that PSM and multivariable logistic
regression modelling are ‘best’ used in combination when investigating the association
between two variables of interest [47, 50, 51]. For this study, the combined use of PSM and
multivariable logistic regression have the following advantages over ordinary logistic regres-
sion. Firstly, PSM minimizes the potential effect of selection bias due to self-selection of moth-
ers who may have breastfed their babies [52, 53]. Secondly, PSM helps to account for the
systematic differences in background characteristics between infants and young children who
were appropriately fed and those who were inappropriately fed [43, 54]. Thirdly, PSM summa-
rises the background characteristics of all study participants into a single measure and relaxes
the linearity assumption of regression analysis [52]. Finally, PSM methods show the area
where there is no sufficient overlap of covariate distributions between the exposed and

unexposed groups, and where estimates using ordinary logistic regression would have relied
on extrapolation [44, 47].
In the present analyses, a five-staged analytical approach was applied to investigate the asso-
ciation between IYCF practices and ARI and diarrhoea. In stage one, the propensity score was
estimated using binary logistic regression by specifying each IYCF indicator to the outcome
and background characteristics (potential confounders) as predictors. The survey weight was
included as a covariate in the estimation process of the propensity score, consistent with previ-
ously published studies [49, 55]. In stage two, the balance in propensity score was checked
between the exposed and unexposed groups (for each of the IYCF) for sufficient overlap (com-
mon support) by examining the propensity score graphs. In stage three, the balance of covari-
ates across the exposed and unexposed groups was checked by calculating the standardized
mean difference (SMD) for each covariate. Less important potential confounders with SMD of
greater than 10% were excluded from further analyses. In stage four, nearest neighbour 1:1
matching with a caliper (0.1) was applied to create a matched exposed and unexposed groups
with equivalent propensity score. Observations that were not in the common support region
(no sufficient overlap in the graph) were excluded from further analyses (S1 and S2 Figs). In
the final stage, multivariable logistic regression was separately used to estimate the association
between IYCF and ARI and diarrhoea. Adjustment for survey year was also conducted, and
interaction tests between potential effect measure modifiers (type of cooking fuel, type of toilet
system and source of drinking water) and each IYCF indicator were conducted.
Odds ratios (ORs) with 95% confidence intervals (CIs) were calculated as the measure of
association between the exposure and outcome variables. We reported the adjusted ORs for
PSM (Table 3) and unadjusted and adjusted ORs for ordinary logistic regression models for
comparison of estimates (S1 Table). Unadjusted ORs for PSM was not reported as potential
confounders are part of the propensity score estimation process in PSM [47]. All analyses were
conducted using ‘svy’ command to adjust for sampling weights, clustering and stratification in
Stata (version 14.0, Stata Corp, College Station, TX, USA). ‘Pscore’ and ‘psmatch2’ were used
for PSM; and the ‘melogit’ function was used for the logistic regression modelling [56].
Ethics approval and consent to participate

The surveys were conducted after ethical approval were obtained from the National Research
Ethics Review Committee (NRERC) in Ethiopia. During the survey, permission from adminis-
trative offices and verbal consent from study participants was obtained before the commence-
ment of data collection. For this study, the datasets used were obtained from Measure DHS/
ICF with approval.
Results
Characteristics of the study participants
Nearly two-thirds of mothers (71.5%) did not attain any schooling, and more than half
(55.0%) of mothers had no employment. Among the study participants, less than half (48.3%)
of mothers were in 25–34 years’ age group. The majority (95.5%) of mothers resided in house-
holds that used improved cooking fuel. More than half (54.8%) of mothers resided in house-
holds that did not use improved source of drinking water [Table 1].
Prevalence of ARI and diarrhoea by IYCF practices

Infants who were exclusively breastfed had a lower prevalence of ARI (9.9%; 95% CI: 8.3%,
11.8%) compared to those who were not exclusively breastfed (15.0%; 95% CI: 12.8%, 17.5%).

Table 1. Characteristics of the study participants in Ethiopia, 2000–2016.

Variables 2000 (N = 3680) 2005 (N = 3528) 2011 (N = 4037) 2016 (N = 3861) 2000–2016 (N = 15,106)
n (%) n (%) n (%) n (%) n (%)
Socioeconomic factors
Maternal education
No schooling 3434 (81.1) 3120 (77.9) 2802 (66.8) 2460 (60.3) 11846 (71.5)
Primary school 582 (13.7) 705 (17.6) 1204 (28.7) 1262 (30.9) 3753 (22.7)
Secondary and higher 220 (5.2) 183 (4.5) 191 (4.5) 360 (8.8) 954 (5.8)
Maternal employment
No employment 1640 (38.7) 2915 (72.8) 2096 (50.4) 2416 (59.2) 9066 (55.0)
Formal employment 373 (8.8) 284 (7.1) 686 (16.5) 508 (12.4) 1851 (11.2)
Informal employment 2222 (52.5) 804 (20.1) 1379 (33.1) 1160 (28.4) 5565 (33.8)
Partner education
No schooling 2599 (62.2) 2230 (56.2) 1989 (48.1) 1744 (45.2) 8562 (53.1)
Primary school 1098 (26.3) 1289 (32.5) 1765 (42.7) 1548 (40.1) 5700 (35.3)
Secondary and higher 480 (11.5) 449 (11.3) 380 (9.2) 569 (14.7) 1878 (11.6)
Household wealth status
Poor 129 5(30.6) 1711 (42.7) 1913 (45.6) 1846 (45.2) 6765 (40.9)
Middle 1197 (28.3) 879 (21.9) 878 (20.9) 859 (21.0) 3812 (12.1)
Rich 1743 (41.2) 1417 (35.4) 1407 (33.5) 1378 (33.8) 5946 (36.0)
Demographic factors
Maternal age
15–24 years 1408 (33.3) 1267 (31.6) 1285 (30.6) 1207 ((29.6) 5167 (31.3)
25–34 years 1936 (45.7) 1900 (47.4) 2077 (49.5) 2067 (50.6) 7980 (48.3)
35–49 years 891 (21) 840 (21.0) 835 (1.9) 809 (19.8) 3375 (20.4)
Family size
�3 471 (11.1) 426 (10.6) 485 (11.6) 484 (11.8) 1866 (11.3)
4–5 1445 (34.1) 1321 (33.0) 1447 (34.5) 1411 (34.6) 5624 (34.0)
6+ 2319 (54.8) 2260 (56.4) 2265 (54.9) 2188 (53.6) 9032 (54.7)
Listening radio
No 3161 (74.7) 2576 (64.3) 2094 (49.9) 2973 (72.8) 10805 (65.4)
Yes 1072 (25.3) 1431 (35.7) 2101 (50.1) 1110 (27.2) 5714 (34.6)
Reading magazine
No 3985 (94.1) 3761 (94.0) 3846 (91.7) 3802 (93.1) 15394 (93.2)
Yes 250 (5.9) 238 (6.0) 349 (8.3) 281 (6.9) 1118 (6.8)
Watching TV
No 4007 (94.7) 3637 (90.9) 2763 (65.9) 3333 (81.6) 13740 (83.3)
Yes 225 (5.3) 363 (9.1) 1428 (34.1) 750 (18.4) 2765 (16.8)
Desire for pregnancy
Desired the pregnancy 3456 (81.6) 3293 (82.2) 3755 (89.5) 3740 (91.6) 14243 (86.2)
Not desired the pregnancy 778 (18.4) 714 (17.8) 442 (10.5) 343 (8.4) 2277 (13.8)
Household factors
Type of fuel for cooking
Improved 256 (6.0) 87 (2.2) 178 (4.3) 215 (5.3) 735 (4.5)
Not improved 3980 (94.0) 3919 (97.8) 4012 (95.7) 3865 (94.7) 15776 (95.5)
Source of drinking water
Improved 1842 (43.5) 2247 (56.1) 1511 (36.0) 1862 (45.6) 7463 (45.2)
Not improved 2394 (56.5) 1760 (43.9) 2686 (64.0) 2221 (54.4) 9060 (54.8)
Type of toilet system
(Continued )

Table 1. (Continued)
Variables 2000 (N = 3680) 2005 (N = 3528) 2011 (N = 4037) 2016 (N = 3861) 2000–2016 (N = 15,106)
n (%) n (%) n (%) n (%) n (%)
Improved 590 (13.9) 387 (9.7) 523 (12.5) 415 (10.2) 1914 (9.5)
Not improved 3646 (86.1) 3620 (90.3) 3674 (87.5) 3668 (89.8) 14608 (88.4)
Health service factors
Ever received vaccine
No 1448 (45.9) 1343 (52.0) 1245 (42.2) 1121 (42.5) 5157 (45.6)
Yes 1705 (54.1) 1238 (48.0) 1690 (57.6) 1518 (57.5) 6151 (54.4)
Antenatal Visit
None 3122 (74.2) 2845 (71.3) 2369 (56.6) 1412 (34.8) 9748 (59.3)
1–3 visits 691 (16.4) 664 (16.6) 1085 (25.9) 1288 (31.7) 3727 (22.6)
4+ visits 396 (9.4) 479 (12) 735 (17.6) 1362 (33.5) 2972 (18.1)
Mode of delivery
Vaginal birthing 4205 (99.5) 3968 (99) 4115 (98.1) 3978 (97.4) 16266 (98.5)
Caesarean section 23 (0.5) 39 (1.0) 82 (1.9) 105 (2.6) 250 (1.5)
Place of birth
Home 4028 (95.1) 3763 (93.9) 3721 (88.7) 2593 (63.5) 14104 (85.4)
Health facility 208 (4.9) 242 (6.1) 476 (11.4) 1490 (36.5) 2416 (14.6)
Delivery assistance
Health professional 3397 (24.1) 432 (11.4) 491 (12.1) 1521 (43.9) 2829 (18.5)
Traditional birth attendant 3103 (22.0) 522 (13.8) 253 (6.2) 1387 (40.0) 3002 (19.6)
Others untrained 7621 (54.0) 2829 (74.8) 3304 (81.6) 560 (16.1) 9460 (61.9)
Timing of postnatal check-up
None 4006 (94.6) 3786 (94.5) 4065 (96.9) 3776 (92.3) 15632 (94.6)
Within a week 179 (4.2) 176 (4.4) 42 (1.0) 154 (3.8) 551 (3.3)
After a week 50 (1.2) 46 (1.1) 90 (2.1) 153 (3.7) 338 (2.10)
Community-level factors
Place of residence
Urban 405 (9.6) 296 (7.4) 558 (13.3) 492 (12.0) 1750 (10.6)
Rural 3831 (90.4) 3711 (92.6) 3639 (86.7) 3591 (88.0) 14773 (89.4)
Region of residence
Tigray 251 (5.9) 242 (6.1) 261 (6.2) 299 (7.3) 1053 (6.4)
Afar 35 (8.4) 37 (9.2) 37 (8.8) 39 (9.6) 149 (1.0)
Amhara 1092 (25.8) 946 (23.6) 923 (22.0) 751 (18.4) 3712 (22.5)
Oromia 1736 (41.0) 1548 (38.6) 1815 (43.2) 1827 (44.8) 6926 (41.9)
Somali 47 (11.1) 153 (3.8) 120 (2.9) 170 (4.2) 490 (3.0)
Benishangul 43 (1.0) 37 (9.3) 48 (1.1) 43 (1.1) 171 (1.0)
SNNPR� 931 (22.0) 953 (23.8) 867 (20.7) 815 (20.0) 3566 (21.6)
Gambella 10 (2.4) 10 (2.5) 13 (3.2) 10 (2.4) 43 (2.6)
Metropolis 89 (2.1) 80 (2.0) 113 (2.7) 130 (3.2) 413 (2.5)
n (%): weighted count and proportion for each variable

�
SNNPR: Southern Nations Nationalities and Peoples Region
https://doi.org/10.1371/journal.pone.0230978.t001
Infants who commenced breastfeeding within the first hour of birth had a lower prevalence of
ARI (13.9%; 95% CI: 12.7%, 15.1%) compared to those whose mothers delayed initiation of
breastfeeding (17.3%; 95% CI: 15.7%, 18.9%) [Table 2]. The proportion of diarrhoea was lower
among infants aged 0–5 months who were exclusively breastfed (7.7%; 95% CI: 6.3%, 9.4%)

Table 2. Prevalence of acute respiratory infection and diarrhoea by infant and young child feeding in Ethiopia, 2000 to 2016.
IYCF factors Prevalence of ARI Prevalence of diarrhoea
a b % (95% CI) P value b % (95% CI) P value
Early initiation of breastfeeding
No 6517 1125 17.3 (15.7, 18.9) <0.001 1607 24.7 (23.0, 26.4) 0.031
Yes 8589 1387 13.9 (12.7, 15.1) 2245 22.5 (21.1, 23.9)
Exclusive breastfeeding
No 2106 316 15.0 (12.8, 17.5) <0.001 331 15.7 (13.6, 18.1) <0.001
Yes 2447 243 9.9 (8.3, 11.8) 188 7.7 (6.3, 9.4)
Predominant breastfeeding
No 1129 162 14.4 (11.6, 17.7) 0.107 172 15.3 (12.6, 18.4) 0.002
Yes 3424 396 11.6 (10.0, 13.4) 347 10.1 (8.8, 11.7)
Introduction of complementary foods
No 1204 227 18.8 (15.5, 22.6) 0.019 322 26.7 (23.3, 30.4) 0.978
Yes 1133 153 13.5 (10.8, 16.8) 303 26.8 (23.2, 30.7)
Continued breastfeeding at 2 years
No 403 48 11.9 (8.0, 17.4) 0.037 80 20.0 (14.9, 26.3) 0.022
Yes 1717 301 17.5 (15.1, 20.3) 470 27.4 (24.1, 31.0)
Bottle feeding
No 13129 2182 15.0 (14.0, 16.1) 0.217 3425 23.6 (22.4, 24.8) 0.200
Yes 1977 330 16.7 (14.2, 19.5) 427 21.7 (19.0, 24.6)
a indicates the total sub-sample in each exposure variables

b indicates weighted count in unmatched data
compared to those who were not exclusively breastfed (15.7%; 95% CI: 13.6%, 18.1%). Infants
aged 0–5 months who were predominantly breastfed had a lower prevalence of diarrhoea
(10.1%; 95% CI: 8.8%, 11.7%) compared to those who were not predominantly breastfed
(15.3%; 95% CI: 13.6%, 18.1%) [Table 2].
Association between IYCF and ARI

EIBF was associated with a lower odds of ARI among infants and young children compared to
their counterparts (OR: 0.81; 95% CI: 0.72, 0.92). Infants who were exclusively breastfed were
less likely to experience ARI compared to those who were not exclusively breastfed (OR: 0.65;
95% CI: 0.51, 0.83). Infants and young children aged 0–23 months who were bottle-fed were
more likely to experience ARI compared to those who were not bottle-fed (OR: 1.36; 95% CI:
1.10, 1.68) [Table 3]. Similar results were observed in ordinary multivariable logistic regression
models, where EIBF and EBF were associated with lower risk of ARI (S1 Table).
Considering the modifying effect of cooking fuel on ARI, multivariate analyses showed that
the relationship between EIBF and ARI was stronger in households with unimproved cooking
fuel. Similar results were evident in the association between EBF and bottle feeding with ARI
[Table 4].
Association between IYCF and diarrhoea

Infants and young children aged 0–23 months who were breastfed within the first hour of
birth were less likely to experience diarrhoea compared to those who were not breastfed within
the first hour of birth (OR: 0.88; 95% CI: 0.79, 0.94). EBF and predominant breastfeeding were
associated with lower odds of diarrhoea among Ethiopian infants (OR: 0.51; 95% CI: 0.39, 0.65

Table 3. The association between infant and young child feeding, and acute respiratory infection and diarrhoea in Ethiopia, 2000 to 2016.
IYCF factors Acute respiratory infection Diarrhoea
� �
Adjusted Adjusted
n OR (95% CI) P value n OR (95% CI) P value
No 4839 1.00 0.001 4832 1.00 0.010
Yes 4839 0.81 (0.72, 0.92) 4832 0.85 (0.75, 0.96)
No 1452 1.00 0.001 1397 1.00 < 0.001
Yes 1452 0.65 (0.51, 0.83) 1397 0.51 (0.39, 0.65)
No 1029 1.00 0.159 1053 1.00 0.006
Yes 1029 0.80 (0.59, 1.09) 1053 0.69 (0.53, 0.89)
No 736 1.00 0.620 825 1.00 0.453
Yes 736 0.92 (0.66, 1.28) 825 1.08 (0.87, 1.35)
No 341 1.00 0.078 358 1.00 0.009
Yes 341 1.59 (0.95, 2.68) 358 1.57 (1.12, 2.21)
Bottle feeding
No 2059 1.00 0.004 2100 1.00 0.173
Yes 2059 1.36 (1.10, 1.68) 2100 (0.95, 1.28)
n: count of IYCF indicators in propensity score-matched data;

�
indicates adjusted ORs in propensity score-matched data
for EBF and OR: 0.69; 95% CI: 0.53, 0.89 for predominant breastfeeding). Children aged 20–23
months whose mothers continued breastfeeding at two years had a higher odds of experienc-
ing diarrhoea compared to those whose mothers discontinued breastfeeding (OR: 1.57; 95%
CI: 1.12, 2.21) [Table 3]. Similar results were evident in ordinary multivariable logistic regres-
sion models, where EIBF, EBF and predominant breastfeeding were associated with lower
odds of diarrhoea (S1 Table).
In the stratified analysis that considered the modifying effect of the type of toilet and source
of drinking water on diarrhoea, EIBF and EBF were strongly associated with lower risk of diar-
rhoea in households with unimproved type of toilet system and source of drinking water
(Table 5).
Discussion
The present study found that EIBF and EBF were associated with a lower risk for infants and
young children to experience ARI in Ethiopia, while bottle-feeding was associated with a
higher risk of ARI. EIBF, EBF and predominant breastfeeding were associated with a lower
risk of diarrhoea among infants and young children in Ethiopia. Continued breastfeeding at 2
years of age was associated with an increased risk of diarrhoea. The associations between EIBF,
EBF and bottle feeding with ARI were stronger in households with unimproved type of cook-
ing fuel. Similarly, in households with unimproved toilet system and source of drinking water,
EIBF and EBF had stronger associations with diarrhoea.
Since 1990, despite substantial declines in global child mortality, respiratory infections still
remain leading causes of death among children younger than five year of age [57]. Evidence

Table 4. Modifying effect of cooking fuel on acute respiratory infection in Ethiopia, 2000–2016.
IYCF factors Acute respiratory infection P for interaction
Type of cooking fuel
n Improved Not improved
� �
OR (95% CI) OR (95% CI)
No 4839 1.00 1.00 0.940
Yes 4839 0.77 (0.33, 1.79) 0.82 (0.72, 0.93)
No 1452 1.00 1.00 0.274
Yes 1452 1.06 (0.33, 3.37) 0.62 (0.48, 0.80)
No 1029 1.00 1.00 0.104
Yes 1029 2.18 (0.66, 7.17) 0.74 (0.53, 1.03)
No 736 1.00 1.00 0.361
Yes 736 0.79 (0.05, 13.28) 0.94 (0.67, 1.32)
No 341 1.00 1.00 0.896
Yes 341 1.64 (0.31, 8.69) 1.75 (1.03, 2.96)
Bottle feeding
No 2059 1.00 1.00 0.379
Yes 2059 1.00 (0.46, 2.20) 1.44 (1.16, 1.78)
n: count of IYCF indicators in propensity score-matched data

�
P for interaction: p-value of likelihood ratio test for the interaction between survey years and a given IYCF indicator
suggests that the increased risk of ARI in children depends on a range of factors, including
sub-optimal breastfeeding, malnutrition, household environment (such as crowding and air
pollution), poor vaccine coverage and antibiotic misuse [57–60]. Consistent with the literature,
our findings showed that children who commenced breastfeeding within the first hour of birth
and were exclusively breastfed had a reduced risk of experiencing ARI compared to their coun-
terparts. The biological mechanism for the protective effect of optimal breastfeeding against
ARI may be due to the presence of immunological substances (such as oligosaccharides,
immunoglobulins, hormones, and enzymes) in breastmilk [61, 62]. These immunological sub-
stances provide passive immunity to the infant, as well as assist in the maturation of the infant
immune system [61, 62]. Also, improved childhood nutrition status from optimal breastfeed-
ing can partially explain the protective effect of breastfeeding against ARI [58, 61].
Evidence has shown that optimal breastfeeding is associated with reduced childhood mor-
bidity and mortality attributable to diarrhoeal diseases [12, 63]. Consistent with past studies [8,
11, 13, 15, 59], this study found that EIBF and EBF were associated with a lower risk of diar-
rhoea. Optimal breastfeeding can reduce the incidence of diarrhoea via three mechanisms.
Firstly, breastfeeding eliminates the infant’s exposure to contaminated foods and fluids. Sec-
ondly, breastmilk provides the infant with anti-microbial and immunological substances that
stimulate the gastrointestinal tract of the infant to develop passive immunity against pathogens
[61, 62]. Finally, breastfeeding improves the nutritional status of the infant which can, in turn,
lower the risk of childhood diarrhoea [58, 61].

Table 5. Modifying effect of water and sanitation on diarrhoea in Ethiopia, 2000–2016.

IYCF factors Diarrhoea P for interaction Diarrhoea P for interaction
Type of toilet Source of drinking water
n Improved, Not improved, n Improved Not improved
� � � �
OR (95% CI) OR (95% CI) OR (95% CI) OR (95% CI)
No 4832 1.00 1.00 0.625 4826 1.00 1.00 0.559
Yes 4832 0.88 (0.68, 1.15) 0.84 (0.75, 0.94) 4882 0.82 (0.71, 0.94) 0.88 (0.76, 1.02)
No 1383 1.00 1.00 0.379 1400 1.00 1.00 0.854
Yes 1383 0.65 (0.30, 1.41) 0.48 (0.37, 0.62) 1400 0.44 (0.30, 0.66) 0.48 (0.34, 0.66)
No 999 1.00 1.00 0.591 995 1.00 1.00 0.613
Yes 999 0.72 (0.37, 1.41) 0.63 (0.47, 0.85) 995 0.63 (0.43, 0.93) 0.72 (0.50, 1.04)
No 746 1.00 1.00 0.392 824 1.00 1.00 0.409
Yes 746 1.02 (0.52, 1.98) 1.02 (0.79, 1.33) 824 1.21 (0.87, 1.69) 1.03 (0.74, 1.46)
No 377 1.00 1.00 0.818 360 1.00 1.00 0.724
Yes 377 1.56 (0.79, 3.09) 1.39 (0.97, 1.99) 360 1.47 (0.92, 2.36) 1.74 (0.91, 3.32)
Bottle feeding
No 2117 1.00 1.00 0.261 2109 1.00 1.00 0.208
Yes 2117 0.91 (0.69, 1.21) 1.11 (0.93, 1.32) 2109 1.00 (0.82, 1.22) 1.23 (0.95, 1.58)
n: count of IYCF indicators in propensity score-matched data

�
P for interaction: p-value of likelihood ratio test for the interaction between survey years and each IYCF indicator
Previous studies conducted in Vietnam [64], Nepal [65], and Brazil [66] have suggested that
predominant breastfeeding, which is the provision of non-milk fluids (such as water, tea, and
juices) in addition to breastmilk to infants, can increase the risk of childhood diarrhoea. How-
ever, the present study found that predominant breastfeeding was associated with a lower odds
of infants to experience diarrhoea in Ethiopia. Our finding was consistent with studies con-
ducted in sub-Saharan African [11, 13, 15] and South Asian countries [39, 40], which showed
that predominant breastfeeding was associated with a lower risk of diarrhoea in children.
Despite the variations in the literature on the health effect of predominant breastfeeding, some
authors have argued that promoting both EBF and predominant breastfeeding may be benefi-
cial to the infant as some studies found lower risk of ARI and diarrhoea among predominantly
breastfed infants [11, 13]. In many African countries, the provision of water and non-milk flu-
ids to infants is a common socio-cultural practice [67–69] (often promoted by the mothers-in-
law and/or grandmothers) [70, 71] as mothers reported that providing water to infants imme-
diately after breastfeeding helps to quench thirst or stop hiccups [69]. However, the provision
of water can be a source of infection for infants and young children in those environments. In
a low income country like Ethiopia, where access to potable water is limited and sanitation is
poor [72], advocating for predominant breastfeeding alongside EBF may predispose infants
and young children to experience diarrhoea.
Based on the immunological, nutritional, hygienic, economic and psychological advantages
of breastfeeding to the infant, the mother and the community [14], the WHO/UNICEF recom-
mends that mothers should continue breastfeeding until the child is two years of age and

beyond [33]. Our study suggested that children who continued breastfeeding at two years of
age had higher odds of experiencing diarrhoea compared to those who had discontinued
breastfeeding at two years of age. This finding was supported by studies conducted in LMICs
that showed the positive relationship between continued breastfeeding and childhood diar-
rhoea [10, 13, 15]. While it is important to introduce complementary foods to infants at
around six months of age, those complementary foods can be contaminated due to unhygienic
preparation, unsafe storage, insufficient cooking time and use of unhygienic feeding utensils
[73, 74]. The concurrent provision of potentially contaminated complementary foods and
breastmilk to children around the age of 2 years could be a possible reason for the observed
association between continued breastfeeding at two years and diarrhoea
Previous research has indicated that breastfed infants have fewer infections and hospitaliza-
tions rate compared to bottle-fed infants [15, 75]. The current study showed that children aged
0–23 months who were bottle-fed had a higher risk of experiencing ARI compared to their
counterparts. Past studies have shown that infants who were bottle-fed had lower opportuni-
ties for receiving antibodies and other immune complexes from their mothers [61, 62]. It is
also possible that the relationship between bottle feeding and ARI is evident because bottle
feeding may promote a higher rate of swallowing and more frequent interruption of breathing,
which may increase the risk for micro-aspiration, and can lead to chest infection [76, 77].
Policy implications of the study findings

Taken together, the present study suggests that interventions aiming to reduce the burden of
ARI and diarrhoea among Ethiopian children should consider context-specific stand-alone
and/or integrated IYCF interventions in both the community and health facility. Relevant pol-
icy initiatives to improve IYCF practice among mothers and subsequently reduce diarrhoea
and ARI burden in Ethiopia have been described in detail elsewhere [78]. This paper will high-
light key interventions alongside the current Ethiopian Government strategy to increase IYCF
practices.
Community-based interventions such as group nutritional education and counselling, fam-
ily or social support, integrated mass media coverage, and community mobilization have been
shown to improve IYCF in LMICs [79]. The successful implementation of any of these com-
munity-based interventions for IYCF would require a wide variety of key community stake-
holders in Ethiopia, including policymakers, health practitioners, experienced behaviour
communication change agents, community and women leaders [80]. A recent study con-
ducted in Ethiopia suggested that sociocultural structure and belief systems (particularly at the
household level) do not fully support the promotion of optimal IYCF [81]. The involvement of
close family members (fathers and/or grandmothers) have been shown to increase optimal
IYCF practices [82–84]. Therefore, community-based interventions that aim to improve IYCF
in Ethiopia must consider the involvement of these close family members who play an impor-
tant role in mothers’ decisions to initiate, cease or continue breastfeeding in the early postnatal
period [85, 86].
Facility-based interventions play a pivotal role in increasing optimal IYCF participation.
For example, the Baby Friendly Hospital Initiatives (BFHI) is an effective approach to increase
breastfeeding in BFHI-certified facilities. The BFHI is a global effort launched by WHO and
UNICEF to implement policies that protect, promote and support breastfeeding [87]. Evidence
on the successful implementation of the BFHI has been published elsewhere [88, 89]. However,
in Ethiopia, none of the health facilities are accredited for BFHI [90], suggesting that Ethiopian
mothers are not receiving appropriate and skilled IYCF support from available health facilities.
This gap in the initiation and implementation of BFHI in Ethiopia suggests that initiating and

implementing BFHI at the health facility level would play a crucial role in improving IYCF
and reduce the disease burden attributable to ARI and diarrhoea in Ethiopia.
In 2008, the Federal Democratic Republic of Ethiopia launched the National Nutrition
Strategy (NNS) to improve child health outcomes, including IYCF [91]. Although significant
improvements in child nutritional status, morbidity and mortality have been observed in Ethi-
opia [21, 22], additional policy interventions are still required. Hence, in 2015, the Govern-
ment of Ethiopia introduced the Health Sector Transformation Plan [27], with the aim to
increase a range of health outcomes for Ethiopians, including IYCF practices. Although this
initiative is needed and well-deserved, there is a need for Ethiopian health stakeholders to
strengthen the BFHI in order to improve IYCF behaviours. This measure is crucial to improve
IYCF and subsequently reduce ARI and diarrhoea burden in Ethiopia because a recent assess-
ment of IYCF scored BFHI service zero out of ten points in the country [90]. Also, future stud-
ies that evaluate the success, challenges and opportunities of the Ethiopian Health Sector
Transformation Plan within the context of the impact on IYCF may be needed to guide refine-
ment of future programs.
Strengths and limitations of the study

The potential limitations that should be considered while interpreting the result of this study
include: firstly, the cross-sectional nature of the study means that clear temporal associations
between IYCF, and ARI and diarrhoea cannot be established. Nevertheless, the observed asso-
ciations are consistent with previously published studies [10, 13, 15]. Secondly, the surveys
were based on self-reported measures which could be a source of recall bias as mothers may
incorrectly reported the number of loose stools passed by the child, however, the study was
restricted to the youngest living child to minimize recall bias.
Thirdly, misclassification bias may have impacted result. This is because the classification of
common cold as ARI or a minimal change to normal bowel habit as diarrhoea, as well as incor-
rect categorization of household-level characteristics such as type of cooking fuel and/or sani-
tation facility. This may have increased or decreased the measure of association between
exposures and outcomes. Fourthly, unobserved confounders such as socio-cultural interac-
tions between the members of the family and across the given community may influence the
relationship between optimal IYCF practices and childhood infections.
Despite the above limitations, using nationally representative data with a high response rate
is a strength in our study. The use of standardized questionnaire for the data collection is also
a strength of this study. Finally, another strength of the study is the adjustment for potential
confounders using the PSM approach in the estimation of the association between IYCF and
ARI and diarrhoea.
Conclusion
EIBF and EBF were protective against ARI and diarrhoea, while bottle-feeding was associated
with a higher odds of ARI in Ethiopian children. Infants who were predominantly breastfed
had a lower odds of experiencing diarrhoea. Our study suggests that community- and facility-
based interventions that targets improved IYCF practices should be prioritised and scaled-up
to reduce the burden of ARI and diarrhoea among Ethiopian children.
Supporting information
S1 Fig. Distribution of propensity scores before and after nearest neighbour (0.1) match-
ing in ARI and IYCF indicator.
(DOCX)

S2 Fig. Distribution of propensity scores before and after nearest neighbour (0.1) match-
ing in diarrhoea and IYCF indicator.
(DOCX)
S1 Table. The association between infant and young child feeding, and acute respiratory
infection and diarrhoea in Ethiopia, 2000 to 2016.
(DOCX)
Acknowledgments
The authors are grateful to Measure DHS, ICF International, Rockville, MD, USA, for provid-
ing the data for analysis. KYA and FAO acknowledge the support of Global Maternal and
Child Health Research Collaboration in the proofreading of the original manuscript.
GloMACH members are Kingsley E. Agho, Felix Akpojene Ogbo, Thierno Diallo, Osita E
Ezeh, Osuagwu L Uchechukwu, Pramesh R. Ghimire, Blessing Jaka Akombi, Pascal Ogeleka,
Tanvir Abir, Abukari I. Issaka, Kedir Yimam Ahmed, Abdon Gregory Rwabilimbo, Daarwin
Subramanee, Nilu Nagdev and Mansi Dhami
Author Contributions
Conceptualization: Kedir Y. Ahmed, Felix Akpojene Ogbo.
Data curation: Kedir Y. Ahmed.
Formal analysis: Kedir Y. Ahmed.
Investigation: Kedir Y. Ahmed, Felix Akpojene Ogbo.
Methodology: Kedir Y. Ahmed, Andrew Page, Amit Arora, Felix Akpojene Ogbo.
Software: Kedir Y. Ahmed, Felix Akpojene Ogbo.
Supervision: Andrew Page, Amit Arora, Felix Akpojene Ogbo.
Validation: Kedir Y. Ahmed, Andrew Page, Felix Akpojene Ogbo.
Visualization: Kedir Y. Ahmed, Andrew Page, Amit Arora, Felix Akpojene Ogbo.
Writing – original draft: Kedir Y. Ahmed.
Writing – review & editing: Kedir Y. Ahmed, Andrew Page, Amit Arora, Felix Akpojene
Ogbo.
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PLOS ONE

Associations between infant and young child

¶ Members of GloMACH are provided in the acknowledgements.

Citation: Ahmed KY, Page A, Arora A, Ogbo FA,

Accepted: March 12, 2020 Methods

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Ethics approval and consent to participate

Prevalence of ARI and diarrhoea by IYCF practices

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Table 1. Characteristics of the study participants in Ethiopia, 2000–2016.

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n (%): weighted count and proportion for each variable

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a indicates the total sub-sample in each exposure variables

Association between IYCF and ARI

Association between IYCF and diarrhoea

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n: count of IYCF indicators in propensity score-matched data;

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n: count of IYCF indicators in propensity score-matched data

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Table 5. Modifying effect of water and sanitation on diarrhoea in Ethiopia, 2000–2016.

n: count of IYCF indicators in propensity score-matched data

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Policy implications of the study findings

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Strengths and limitations of the study

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J. 2016; 12:16. Epub 2017/04/14. https://doi.org/10.1186/s13006-017-0110-4 PMID: 28405212;

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