Time to breastfeeding cessation and its predictors among mothers who have children aged two to three years in Gozamin district, Northwest Ethiopia: A retrospective follow-up study.

INTRODUCTION: Globally, breastfeeding duration is below the recommended level. In Ethiopia, more than 24% of mothers ceased breastfeeding before 24 months of age of a child which caused 14,000 preventable childhood deaths annually. To tackle this problem, current and up-to-date information regarding the time to breastfeeding cessation and its predictors is essential. Therefore, this study aims to determine the time to breastfeeding cessation and its predictors among mothers who have children aged two to three years in Gozamin district, Northwest Ethiopia.
METHODS: A community-based retrospective follow-up study was used among 502 mothers who have children aged two to three years in the Gozamin district from October 1, 2017, up to September 30, 2020. Interviewer-administered structured questionnaires were used. Cox proportional hazard model was applied after its assumptions and model fitness were checked, to identify predictors for time to breastfeeding cessation.
RESULTS: The overall mean time to breastfeeding cessation was 22.56 (95%CI: 22.21, 22.91) months, and the cumulative survival probability on breastfeeding up to 24 months was 82.5% (95%CI:78.85, 85.53). The overall incidence of early breastfeeding cessation was 7.77 (95%CI:6.31, 9.58) per 1000 person-month observations. Having no antenatal care follow up (AHR:2.15, 95%CI:1.19, 3.89), having ≥4 number of children (AHR:1.76, 95%CI:1.10, 2.80), < 24 months breastfeeding experience (AHR:1.77, 95%CI:1.14, 2.75), and presence of cow milk in the household (AHR:3.01, 95%CI:1.89, 4.78) were significant predictors for time to breastfeeding cessation.
CONCLUSION: The time to breastfeeding cessation is below the recommendation and therefore, strengthening breastfeeding education and related counseling at the community level is better.

Introduction

Breastfeeding is a natural practice that is considered by almost all mothers at birth that gave breast milk for the healthiest start of the life of children [1, 2]. It promotes cognitive development, acts as a baby’s first vaccine, providing critical protection from disease and death of a child and it also promotes maternal health by preventing breast cancer, ovarian cancer, and type II diabetes mellitus, which further lowers health care costs, and strengthening the development of nations by creating healthier families [2, 3].

World Health Organization (WHO) and United Nations Children Fund (UNICEF) recommended that children should breastfeed for six months exclusively and should continue up to the second birth date or above [4, 5]. Breast milk gives all nutritional requirements for six months of age and half of all nutritional requirements onwards up to one year of age [6, 7]. Breastfeeding from one up to two years of age also provides one-third of the nutritional requirements of the child [6].

Despite these benefits breastfeeding duration is below the recommended level. Worldwide more than one-third of children are ceased breastfeeding before two years among children aged 12–23 months [4]. In the poorest families also 36% of children ceased breastfeeding before their second year of birth [1]. Similarly, in southern and eastern Africa 29% of children were not benefiting from the recommendation of breastfeeding [4]. More than 24% of children in Ethiopia also ceased breast milk consumption contrary to the WHO recommendation [8].

Breastfeeding cessation before a recommended level could cause 823,000 deaths in under-five children and 20,000 mothers’ death from breast cancer worldwide annually [9]. In sub-Saharan countries, 334,892 deaths of children occurred due to cessation of breastfeeding before WHO recommendation [10]. The risk of mortality due to infectious-related causes was also twofold higher among children who ceased breastfeeding when compared to breastfed children aged 6–23 months [11] and specifically, diarrheal-related morbidity and mortality was 2.18% in children who ceased breastfeeding during this period [12]. In Ethiopia also 14, 000 preventable childhood deaths and 5 million cases of diarrhea and pneumonia were occurred annually because of breastfeeding cessation before the recommended time [13].

Different sociodemographic related factors such as the age of the mother, marital status of the mother, educational status of the mother, occupation, wealth index, and the number of children were factors identified as predictors for time to breastfeeding cessation from previous works of literature [14-21]. Similarly, obstetric-related predictors, health service-related predictors, and nutrition-related predictors were also identified as factors for time to breastfeeding cessation [14, 22–27] (Fig 1).

Fig 1

Conceptual framework for time to breastfeeding cessation and its predictors among mothers who have children aged two to three years in Gozamin district, Northwest Ethiopia, 2020.

Despite the Ethiopian government’s effort on breastfeeding promotion and awareness creation, a significant number of children are still vulnerable to the effect of early breastfeeding cessation, and also the duration of breastfeeding is variable among regions with a decreasing trend over time [28]. Postpartum insusceptibility due to breastfeeding had an inhibiting effect on fertility among rural areas in the Amhara region of Ethiopia where breastfeeding duration was long [29], but the duration of breastfeeding is in a declined trend which was not searched well [28]. Previous studies on breastfeeding cessation (mostly exclusive breastfeeding cessation) were concentrated on the urban or at the institution level [22, 30]. Hence, there is limited data in this area especially in the rural part of Ethiopia, assessing the time to cessation of breastfeeding and its predictors in the rural part of Gozamin District is crucial for up-to-date information and scientific-based decision making and intervention. Therefore, this study assesses the time to breastfeeding cessation and its predictors among mothers who had children aged two to three years in Northwest Ethiopia of Gozamin District.

Methods

Study design

A community-based retrospective follow-up study design was used.

Study area and period

This study was conducted at Gozamin district, which is located in East Gojjam Zone, Northwest Ethiopia, 299 km from Addis Ababa, the capital city of Ethiopia, and 265km from Bahir Dar, the regional capital city of Amhara. The District has 30 Kebeles (a Kebele is the lowest administrative level in Ethiopia) which has 22,316 under-five children, 12,872 under three years’ children, 8,323 are under two years and 4,549 children are aged two to three years based on the Gozamin district health information system data and 2020 annual health office report (Gozamin district Health Office plan and performance annual report, 2020: 218.).

This study was conducted from October 1, 2017, to September 30, 2020, among mothers who have children aged two to three years, and data were collected from October 1, 2020, to November 30, .2020.

Population

Source population

All mothers who have children aged two to three years in Gozamin District.

Study population

Mothers who have children aged two to three years living at selected Kebeles of Gozamin District during the data collection period were included in the study.

Exclusion criteria

Those mothers who were seriously ill and then become unable to communicate. Mothers who have a child aged two to three years not initially breastfed at least once were excluded. Mothers who gave care and breastfed other than their children were also excluded from this study.

Sample size determination and procedures

Sample size determination

The sample size for this study was calculated using the general formula of sample size calculation for time to event data [31]:

Probability of event(p(E)) = 1-(p1s1(t) + p2s2(t))

in which z a/2 = 1.96 at 0.05 significant level, z1-B = 80% power, p1 = proportion of population allocated to a non-exposure group, p2 = proportion of population allocated to exposure group, non-response rate (W) = 10%, design effect = 2, survival probability ((s1(t) and s2(t) of a non-exposed group and exposed group respectively)) and Hazard ratio of predictors was taken from the literature [22]. Then Stata 14.1 software was used. Finally, the total sample size was 516 mother-child pairs.

Sampling procedures

The overall sampling procedure used was the multistage sampling technique. From thirty kebeles in the district, ten Kebeles were selected by simple random sampling technique having a total of 1673 eligible mother-child pairs, out of which 516 eligible participants were selected. Then the eligible participants were allocated for each kebele using the population proportion formula. Using a systematic random sampling technique, mother-child pairs were selected with a sampling interval of three eligible households. Finally, to obtain mother-child pairs needed for this study, data collectors moved every household within the selected kebele.

Variables of the study

Dependent variable

Time to breastfeeding cessation.

➢ Age of mother

➢ Marital status of the mother

➢ The educational level of the mother

➢ Occupation

➢ Wealth index

➢ Number of children

➢ Antenatal care follow-up

➢ Place of delivery

➢ Mode of Delivery

➢ Immunization follow-up

➢ Breastfeeding experience

➢ Starting time of complementary feeding

➢ Formula milk use status

➢ Presence of cow milk at household

Operational definitions

Breastfeeding cessation

Breastfeeding was stopped before 24 months of age of a child.

Event

Stopped breastfeeding before 24 months of age of a child as reported by the mother during the data collection period.

Censored

A mother who was breastfed the child during the data collection period or ceased after two years.

Survival time

The time from initiation of breastfeeding (birth) until the cessation or censoring of breastfeeding in months.

Wealth index

A score was given to each household based on the relative ownership of assets of the house. These scores were derived using principal component analysis. Finally, the household’s wealth has been categorized as poor (1), middle (2), and rich (3) based on the wealth status score [28, 32].

Data collection tools and procedures

A structured questionnaire was developed and adapted from works of literature written in the Ethiopian context [22, 28]. The questionnaire contains maternal sociodemographic, obstetric, health service, and nutritional-related predictors.

Data were collected using smartphone-assisted interviewer-administered questionnaires through EPI-INFO android version 7.2 software. For data collectors, supervisors, and the principal investigator, EPI-INFO version 7.2 was installed on their smartphones and then the template of the questionnaire was loaded. Data were collected at a time when mothers were easily accessed at home such as weekends or holidays of the community through assisting guiders. The survival data has been collected from mothers who had children aged two to three years. Mothers were asked to answer the date of breastfeeding cessation, and the child’s birth date was the beginning point of the retrospective follow up study, and the endpoint of the follow-up study was taken as the date of breastfeeding cessation or the end of the study, which was the length of the survival time. The event of interest for this study was mothers who had stopped breastfeeding before 24 months of the child, and those breastfed during data collection or stopped after 24 months were right-censored. Mothers who were not presented during the data collection time were further considered the next two holy or weekend days and then after, the mother was considered as non-response mother-child pairs.

Data quality assurance

To maintain data quality, the principal investigator trained four data collectors and two supervisors for two days. A pretest was conducted on 26 mother-child pairs (5%) from a non-selected kebele. After the pretest, part of the questionnaire which was not easily understood by the respondents was modified. Some variables missed during the pretest were added to the final questionnaire. On-site supervision was performed and each synced file of the questionnaire was sent by each data collector on daily basis to the email of the principal investigator for completeness and accuracy checking before leaving the study area.

Data processing and analysis

Data were collected and entered into EPI-INFO version 7.2 and exported to Microsoft office excel 2016, and then further exported to Stata 14.1 for further coding, cleaning, and analysis. Checking for missing values and, the presence of influential outliers was evaluated.

Months were used as a time scale to measure the time to breastfeeding cessation. Each participant’s outcome was dichotomized into the event and censored coded as “1” and “0” respectively. Descriptive statistics such as mean (standard deviation) for normally distributed data, median (interquartile range), frequencies, and proportions were used to describe the characteristics of the study participants. To estimate the breastfeeding survival status of the mother Kaplan-Meier survival curve and the log-rank test was used. A life table was also used to estimate the cumulative survival probability of mothers breastfeeding up to 24 months. The incidence rate of early cessation of breastfeeding of mothers was calculated as the number of events over the person-months of follow-up.

The Cox Proportional Hazard (PH) assumptions were checked using Schoenfeld residuals statistical test, presence of time-dependent covariate, and graphical methods. The model adequacy was also checked using the Cox-Snell residuals graph and Schoenfeld residuals statistical global test.

Bi-variable Cox regression model building was done for each independent variable and outcome of interest to identify potentially significant variables with a significant test ≤ 0.2 for the multivariable Cox proportional hazards regression model. Then, multivariable analysis was started with a model containing all of the selected variables, and then a stepwise backward regression procedure was applied.

Hazard ratio (HR) with 95% confidence intervals (CI) was used to interpret the result of the final model. Statistical significance was declared at the p-value is less than 0.05. Finally, the result of this study was presented using tables, graphs, or text narrations.

Ethical procedures

Ethical clearance was obtained from the ethical review committee of Debre Markos University, College of Health Sciences (Ref. No: HSC/R/C/Ser/Co/43/11/13) for the Gozamin district Health office, and permission was obtained. All information collected from mothers was kept strictly confidential by excluding Personal identifiers from the questionnaire and codes were used. Oral informed consent and then finger stamped signature from the mothers were obtained.

Result

Out of 516 mother-child pairs that were entered into the study, 502 mother-child pairs were responded at the data collection period and gave a response rate of 97.3%.

Socio-economic and demographic characteristics

The mean baseline age of mothers was found to be 28.4 ± 6.08 SD years. Among the total 502 mother-child pairs, 449 (89.44%) were married and 368 (73.31%) have no formal educational level. The median age of children was 29 (IQR = 26–33) months. Among 16 never-married mothers, 7 were ceased breastfeeding their children early during the follow-up time of this study. Likewise, among mothers who had four and fewer children in their household, 60 (15.38%) mothers have ceased breastfeeding before 24 months (Table 1).

Table 1

Socio-economic and demographic characteristics of mother-child pairs in Gozamin district, Northwest Ethiopia from October 1/2017-September 30/2020.

Variable	Category	Number(%)	BFC Status**
			Event (%)	Censored(%)
Maternal age	15–24	133 (26.49)	26 (29.55)	107 (25.85)
	25–34	285 (56.77)	42 (47.73)	243 (58.70)
	35 and above	84 (16.73)	20 (22.73)	64 (15.46)
Marital status of the mother	Married	449 (89.04)	76 (86.36)	373 (90.10)
	Never married	16 (3.19)	7 (7.95)	9 (2.17)
	Widowed/Divorced	37 (7.37)	5 (5.68)	32 (7.73)
Educational level of the mother	No Education	368 (73.31)	63 (71.59)	305 (73.67)
	Primary education	72 (14.34)	11 (12.50)	61 (14.73)
	2ndary education and Higher	62 (12.35)	14 (15.91)	48 (11.59)
Occupation of the mother	Housewife	404 (80.48)	71 (80.68)	333 (80.43)
	Employed	48 (9.56)	6 (6.82)	42 (10.14)
	Daily Laborer	26 (5.18)	5 (5.68)	21 (5.07)
	Others*	24 (4.78)	6 (6.82)	18 (4.35)
Number of children	≤4	390 (77.69)	60 (68.18)	330 (79.71)
	>4	112 (22.31)	28 (31.82)	84 (20.29)
Wealth index	Poor	168 (33.47)	30 (34.09)	138 (33.33)
	Middle	220 (43.82)	38 (43.18)	182 (43.96)
	Rich	114 (22.71)	20 (22.73)	94 (22.71)

Others* include Tea/coffee/local beer sellers, students BFC status** = breastfeeding cessation.

Obstetric and health service utilization characteristics of respondents

Out of the total mothers enrolled in the study, 457 (91.04%) had ANC follow-up. Among mothers who ceased breastfeeding early, 71 (80.68%) had ANC follow up of which 24 and 47 of them had <4 and ≥4 number of visits respectively (Table 2).

Table 2

Obstetric, breastfeeding, nutrition-related factors and health service utilization characteristics of mother-child pairs in Gozamin district, Northwest Ethiopia from October 1/2017-September 30/2020.

Variable	Category	Number(%)	BFC status**
			Event (%)	Censored(%)
Antenatal care follow up	No	45 (8.96)	17 (19.32)	28 (6.76)
	< 4	133 (26.49)	24 (27.27)	109 (26.33)
	≥4	324 (64.54)	47 (53.41)	277 (66.91)
Place of delivery	Home	132 (26.29)	27 (30.68)	105 (25.36)
	Health Institution	370 (73.71)	61 (69.32)	309 (74.64)
Mode of delivery	Vaginal delivery	460 (91.63)	78 (88.64)	382 (92.27)
	Cesarean section	42 (8.37)	10 (11.36)	32 (7.73)
Immunization follow up status	Yes	444 (88.45)	69 (78.41)	375 (90.58)
	Interrupted	36 (7.17)	11 (12.50)	25 (6.04)
	No	22 (4.38)	8 (9.09)	14 (3.38)
Breastfeeding Experience	Yes	382 (76.10)	69 (78.41)	313 (75.60)
	No	120 (23.90)	19 (21.59)	101 (24.40)
Starting time of complementary feeding	< 6 months	30 (5.98)	12 (13.64)	18 (4.35)
	= 6 months	305 (60.76)	52 (59.09)	253 (61.11)
	>6 months	167 (33.27)	24 (27.27)	143 (34.54)
Use of formula milk status	Yes	40 (7.97)	9 (10.23)	31 (7.49)
	No	462 (92.03)	79 (89.77)	383 (92.51)
Presence of cow milk at HH*	Yes	62 (12.35)	26 (29.55)	36 (8.70)
	No	440 (87.65)	62 (70.45)	378 (91.30)

BFC status** = breastfeeding cessation HH* = Household.

Breastfeeding and nutritional related characteristics of respondents

Among the total observations, 382 (76.10%) of mothers had breastfeeding experience and of these 54 (14.14%) had below 24 months of experience. Three hundred five (60.76%) of participants had started at the right time of complementary feeding initiation for their current child, but 30 (5.98%) and 167 (33.67%) had started complementary feeding before and after six months of age respectively (Table 2).

Survival status of mothers on breastfeeding

Among 502 observations followed, 414 (82.47%) observations were censored at the end of the study. The minimum and maximum follow-up time of the cohort was 2 months and 24 months respectively. The median follow-up time of the cohort was 24 months.

From the life table, the cumulative survival probability of breastfeeding up to 12, and 24 months were 0.968, and 0.825 respectively. Therefore, the proportion of mothers who breastfed the current child until 24 months was 82.5% (95%CI: 78.85%, 85.53%) (Table 3).

Table 3

Cumulative failure probability of breastfeeding among mothers who have children aged two to three years in Gozamin district from October 1/2017-September 30/2030.

Time interval (Months)	Population entered into the interval	Event	Censored	Cumulative failure probability	95% Confidence interval
6	502	7	0	0.0139	0.0067, 0.0290
12	495	9	0	0.0319	0.0196, 0.0515
18	486	25	0	0.0817	0.0608, 0.1093
24	461	47	414	0.1753	0.1447, 0.2115

The overall survival time on breastfeeding was also estimated by the Kaplan-Meier survival curve, which indicated the slow occurrence of events over the follow-up period (Fig 2). The survival estimates on breastfeeding were varied with antenatal care follow-up, starting time of complementary feeding, and presence of cow milk in the household. This survival status was compared and tested significant statistically using a log-rank test (Figs 3–5).

Fig 2

The Kaplan-Meier survival estimates of time to breastfeeding cessation among mothers who have children aged two to three years in Gozamin district, Northwest Ethiopia from October 1/2017-September 30/2020.

Fig 3

The Kaplan-Meier survival estimates graph by antenatal care follow up of the mother for time to breastfeeding cessation among mothers who have children aged two to three years in Gozamin district, Northwest Ethiopia from October 1/2017-September 30/2020.

Fig 5

The Kaplan-Meier survival estimates graph by presence of cow milk at household of the mother for time to breastfeeding cessation among mothers who have children aged two to three years in Gozamin district, Northwest Ethiopia from October 1/2017-September 30/2020.

The mean time to cessation of breastfeeding was 22.56 months (95% CI: 22.21, 22.91). Among those who ceased breastfeeding early, the median time to cessation of breastfeeding was 18 (IQR = 12–20, 95%CI: 15, 19) months.

Incidence of early breastfeeding cessation

Out of the total observations, 88 (17.53%) mothers have ceased breastfeeding before 24 months with an overall incidence rate of 7.77 per 1000 (95% CI: 6.31, 9.58) person-month observations after 11325-lifetime risk follow-up months.

From the total events, the highest incidence of breastfeeding cessation was observed at end of the 18th and 24th months of follow-up with the incidence rate of 8.21 (95%CI:5.45, 12.35) and 13.88 (95%CI: 10.01, 19.25) per 1000 person-months observations respectively. Besides the incidence of breastfeeding cessation before 6 and 12 months of follow-up were 3.67 (95%CI: 2.03, 6.62) and 6.14 (95%CI: 3.87, 9.74) per 1000 person-month observations respectively. Likewise, the incidence rate of early breastfeeding cessation among mothers who had no antenatal care follow-up and had cow milk in the household was 17.95 (95%CI:11.16, 28.88) and 20.34 (95%CI:13.85, 29.88) per 1000 person-months observations respectively.

Predictors of time to breastfeeding cessation

Predictors that had an association at p-value ≤0.2 in bi-variable cox proportional hazard regression were included in multivariable regression. Accordingly, age of the mother, marital status of the mother, educational status of the mother, number of children, antenatal care follow-up, mode of delivery, immunization follow-up, breastfeeding experience, starting time of complementary feeding, and presence of cow milk at household were included into multivariable cox proportional hazard regression model. Finally, after the stepwise backward elimination approach four variables such as >4 number of children, having no antenatal care follow up, having <24 months breastfeeding experience and presence of cow milk at household were statistically significant predictors of time to breastfeeding cessation at p-value <0.05 level of significance (Table 4).

Table 4

Bi-variable and multivariable cox proportional hazard regression analysis of predictors of time to breastfeeding cessation among mothers who had children aged two to three years in Gozamin district from October 1, 2017-September 30/2020.

S.no	Variables	CHR (95%CI)	AHR (95%CI)	P-value
1	Number of children
	≤ 4	1	1
	>4	1.70 (1.09, 2.68)	1.76 (1.10, 2.80)	0.018
2	Antenatal care visit
	≥4	1	1
	<4	1.30 (0.79, 2.12)	1.24 (0.76, 2.04)	0.391
	No	2.96 (1.70, 5.16)	2.15 (1.19, 3.89)	0.011
3	Breastfeeding experience
	≥24 months	1	1
	<24 months	1.8 (1.23, 2.84)	1.77 (1.14, 2.75)	0.011
4	Immunization follow-up
	Fully	1	1
	Not fully	2.26 (1.36, 3.75)	1.50 (0.87, 2.57)	0.143
5	Presence of cow milk
	No	1	1
	Yes	3.49 (2.21, 5.52)	3.01 (1.89, 4.78)	<0.001

Having greater than four children at household was a statistically independent sociodemographic predictor of time to breastfeeding cessation in which mothers who had ≥4 number of children were 1.76 times (AHR = 1.76, 95%CI:1.11,2.80) higher to ceased breastfeeding early than mothers who had ≤4 number of children at household. The risk of early breastfeeding cessation was 2.15 times higher among mothers who had no antenatal care follow-up than mothers who had ≥4 antenatal care follow up (AHR = 2.15, 95%CI:1.19, 3.89). Similarly, the risk of early breastfeeding cessation was 1.77 times higher among mothers who had less than 24 months of breastfeeding experience than mothers who had ≥24 months breastfeeding experience (AHR = 1.77, 95%CI:1.14, 2.75). The presence of cow milk in the household was also a statistically independent predictor of time to breastfeeding cessation in which the risk of early breastfeeding cessation was 3.01 times higher than mothers who had no cow milk at their household (AHR = 3.01, 95%CI:1.89, 4.78) (Table 4).

Discussion

Cessation of breastfeeding before the recommended time increases the risk of developing diarrhea, respiratory infectious disease, and death of a child, which further affects child survival and morbidity [33, 34]. In Ethiopia, more than 24% of children are vulnerable to the effect of breastfeeding cessation [8]. Therefore, this study assesses the incidence rate and the mean time to breastfeeding cessation, and its predictors among mothers who have children aged two to three years in the Gozamin district.

The overall incidence rate of breastfeeding cessation before 24 months of age of the child was 7.77 per 1000 person-month observations. This finding is lower than the finding of the study conducted in Debre Markos town which reported that the overall incidence rate of breastfeeding cessation before 24 months of age of the child was 13.70 per 1000 person-month observations [22]. It might be due to socioeconomic differences between the urban and rural study populations of the two studies. Similarly, the finding of the study in Iran, Tehran was 16.02 per 1000 person-months observation, which is higher than the finding of the present study [14]. The reason may be the present study is a community-based retrospective follow-up study which may have a relatively high recall bias than register-based follow-up studies. This may underestimate the incidence rate of breastfeeding cessation before 24 months of age of the child.

The finding of this study stated that the proportion of mothers who were breastfeeding up to the 24th month of follow-up was 82.5%. This finding is higher than the finding of the study done in Debre Markos town, which indicated that the proportion of mothers breastfeeding until the 24th month of the life of the child was 68.5% [22]. The reason might be the finding of the current study was based on rural mother-child pairs which were mainly less-educated mothers who tended to breastfeed for a longer time. Likewise, the proportion of mothers to breastfeed their children up to 24th months of age was 72.1% done in Ethiopia at the national level, which is less than the finding of the current study [8]. It might be due to the sociodemographic difference of the study population by the national study and it also incorporated urban mothers intended to cease early than the rural mothers.

The overall estimated mean time to breastfeeding cessation was 22.56 months, which means that as mothers’ followed for 24 months, the survival time on breastfeeding of the current child was averagely estimated as 22.56 months. This finding is higher than the finding of the study done in Iran, Tehran, which is 21.49 months [14]. This might be due to the present study being done on rural mothers who might breastfeed for a longer duration than urban mothers. As urban mothers are more educated than rural mothers, the probability of engaging in full-time work is higher than rural mothers which leads to early cessation of breastfeeding.

The risk of early breastfeeding cessation was higher among mothers who had More than 4 children as compared to mothers who had ≤4 children. This finding is supported by the finding of the study done in Debre Markos town, Ethiopia, which stated that mothers having a higher number of children were at higher risk of early breastfeeding cessation than mothers having a lower number of children [22]. The possible justification might be as the number of children in the household increases the workload of the mother for caring for children is increased. The time for breastfeeding the current child decreases gradually which makes the mother to ceased breastfeeding early.

The risk of early breastfeeding cessation was higher among mothers who had no antenatal care follow-up as compared to mothers who had four and above antenatal care follow-up. The finding of this study is opposite to the finding of the study done in Bangladesh [25]. The difference might be in Bangladesh urban mothers received more antenatal care than rural mothers who breastfed shorter duration [35]. This finding is supported by the finding of the national study in Ethiopia reported that mothers who didn’t receive antenatal care services had a 10% shorter duration of breastfeeding than mothers who received 4+ antenatal care services [32]. This might be as a mother receives more antenatal care service, counseling regarding breastfeeding, and its duration was increased, which further increases the knowledge of a mother on the advantages of longer duration of breastfeeding.

Breastfeeding experience less than 24 months was a risk factor for early breastfeeding cessation. This finding is supported with the finding of the study done in China, Wuhan, which stated that short previous breastfeeding duration and negative previous breastfeeding experience have an unfavorable effect on subsequent breastfeeding duration [27]. The reason might be longer breastfeeding experienced mothers’ had better breastfeeding attitudes, confidence, self-efficacy, motivation, and intention for a longer duration of breastfeeding [36].

The presence of cow milk in the household during the last 24 months is an independent statistically significant predictor of time to breastfeeding cessation in this study. Mothers who had cow milk in the household have a higher risk of early breastfeeding cessation. This finding is consistent with the study done in southern Ethiopia [23]. The reason behind this may be mothers who have cow milk at their own home may give it as a substituent for breast milk starting from early life that may lead to early cessation of breastfeeding. This is evidenced in which mothers gave cow milk even before six months of age of the child [37].

Limitation of the study

It is a retrospective study, there might be recall bias, possibly resulting in over or underestimation of actual time to breastfeeding cessation. The survival time of breastfeeding duration for this study is determined using a restricted mean, which may underestimate the overall time to breastfeeding cessation. Due to the retrospective nature of the study, some variables such as the perception of sufficient milk supply, knowledge, and attitude of mothers were not assessed.

Conclusion

This study assessed the incidence rate and time to breastfeeding cessation. The incidence rate of early breastfeeding cessation was 7.77 per 1000-person month observations which is lower than previous works of literature. The mean time to breastfeeding cessation was 22.56 months which is below the WHO recommendation. Having >4 number of children, having no antenatal care follow-up, <24 months breastfeeding experience and presence of cow milk were statistically significant predictors of time to breastfeeding cessation. However, immunization follow-up and <4 number of antenatal care follow-up were not statistically significant predictors.

Therefore, stakeholders better to take measures further to prolong the duration of breastfeeding through incorporating these significant predictors as one part of breastfeeding counseling and education at the community level.

(DTA)

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(ZIP)

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18 Oct 2021

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Please address the comments and suggestions of the two reviewers satisfactorily. Please also make sure that the revised manuscript follows PLOS One guidelines about formatting and referencing and it is edited for English language.

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When submitting your revision, we need you to address these additional requirements.

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2. Thank you for including your ethics statement:  "Debre Markos University, College of Health Sciences Ref. No: HSC/R/C/Ser/Co/43/11/13".

Please amend your current ethics statement to confirm that your named institutional review board or ethics committee specifically approved this study.

Once you have amended this/these statement(s) in the Methods section of the manuscript, please add the same text to the “Ethics Statement” field of the submission form (via “Edit Submission”).

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5. In your Data Availability statement, you have not specified where the minimal data set underlying the results described in your manuscript can be found. PLOS defines a study's minimal data set as the underlying data used to reach the conclusions drawn in the manuscript and any additional data required to replicate the reported study findings in their entirety. All PLOS journals require that the minimal data set be made fully available. For more information about our data policy, please see http://journals.plos.org/plosone/s/data-availability.

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We will update your Data Availability statement to reflect the information you provide in your cover letter.

6. We note that you have referenced "GDHO. Gozamin district Health Office plan and performance annual report, 2012 E.C.pdf. In: office DH, editor. annual ed. Unpublished ppt2020. p. 218" which has currently not yet been accepted for publication. Please remove this from your References and amend this to state in the body of your manuscript: "GDHO. Gozamin district Health Office plan and performance annual report, 2012 E.C.pdf. In: office DH, editor. annual ed. Unpublished ppt2020. p. 218" as detailed online in our guide for authors

http://journals.plos.org/plosone/s/submission-guidelines#loc-reference-style.

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In your revised cover letter, please address the following prompts:

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We will update your Data Availability statement on your behalf to reflect the information you provide.

[Note: HTML markup is below. Please do not edit.]

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Partly

Reviewer #2: Partly

**********

2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: I Don't Know

Reviewer #2: I Don't Know

**********

3. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

Reviewer #2: Yes

**********

4. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #2: No

**********

5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: Major comments

Title

You are using two terms (time and early) with similar meaning. I would suggest removing either of them.

The title is not clearly stated. I suggest: Early breastfeeding cessation and its predictors among mothers with two to three years old children in Gozamin....

Corresponding author

No need to mention these details here, put the adress next to your address above. To show the coresponding author, put * next to the name then mention what the * means. * Corresponding author

Abstract: What is the importance of mentioning the last sentence in the introduction? Delete it and add the aim/objective of your study

Methods (page 5)

I do not think that the you have used proper study design

You have explained too much about study area which is less important, try to summarize in few sentences.

What is your justification to take this timeframe October 2017 to September 20202?

The inclusion criteria is similar with the study population, try to summarize the subheadings and avoid repetition.

Exclusion criteria (last two lines), Not clear what you want to say? revise it

Sampling procedure: What is the total number of Kebele, from how much did you select ten?

Why do you use the word "infant chaild pairs" Have you collect any data from the child? I would suggest to use mothers....

data collection: I do not know why you have taken date of birth as starting point? it is obvious.

Your dependent variable is early BF cessation before 24 months and the participants are mothers with children 2-3 yeaars. So why are you using retrospective follow up design? which is used to assess the outcome of certain exposure. I think the design you have used is not correct. I am ready to hear your explanation about this.

The last three lines of page 8: To answer this, why do you use retrospective follow up? because it is obvious that they have started after birth then stopped in one specific time.

Data collection tool: This should come before data collection. I would suggest to merge with the above sub headings.

What was the findings of your pre test, summarize in one or two sentences. was there any problem with the tool? what do you find from your pretest?

Results

First sub title: Why are you referring as baseline? it is confusing. do you have any data taken during follow up? I think such category is used for multiphase study but yours is single phase study. Therefore, better to sat Sociodemographic characteristics

Fourth line of first sub heading: Did you had any follow up time in your study? I this the main problem is related to the study design.

What is the importance of mentioning this as incidence?

Minor comments

Title page: Be consistent, you have added affiliation to 2 and 3 but 1 and 4 did not have affiliation.

Put each email next to their address

Abstract: add comma to 14000, in the conclusion you have used different line spacing

data collection procedure there is a word "For 4 data collectors.... What? not clear

There are grammatical errors, the language need revision

Reviewer #2: The draft manuscript should convince clearly with evidence the breastfeeding cessation is a critical issue in Ethiopia. Otherwise, the analyses objective should be revised to be appropriated with the country evidence-based breastfeeding issue. There is a need for the study to develop a theory of what factors and their mechanisms to predicting the breastfeeding behaviour. The arguments provided in the background is often inconsistent (See my attached written review).

**********

6. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: No

Reviewer #2: No

[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.]

While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step.

Submitted filename: BU Review BF Cessation for PLOS ONE 30 Sep 2021.docx

Click here for additional data file.

25 Oct 2021

Response to Reviewers

Author Feedback: Dear editors and reviewers of this manuscript, we have no sufficient words to give our gratitude for your devotion of time and energy to improve the manuscript sufficient enough to be ready for production and then publication. As per your comments, we have tried to improve the manuscript and gave responses to those comments one by one. Dear editors and reviewers, even further we are ready to hear your comments and improve accordingly. Thanks a lot.

[Note: HTML markup is below. Please do not edit.]

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Partly

Reviewer #2: Partly

Author Response: yes, it is sounded technically as all research procedures were implemented accordingly. To assure this the data set which is in Stata format (.DAT) was attached as a supportive file.

2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: I Don't Know

Reviewer #2: I Don't Know

Author response: yes, the appropriate and robust way to analyze time to event type of data was Cox regression, which is a popular and semiparametric type of modeling that nearly gives results obtained by parametric type of modeling in survival analysis at which data distribution was not well known. Hence, “time to breastfeeding cessation” is an outcome variable having a time-to-event nature that is handled by cox regression modeling with the assumptions of modeling were fulfilled. So the statistical analysis was performed using this modeling technique, it is appropriate.

3. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exceptions (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians, and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

Reviewer #2: Yes

Author response: Yes, all data used for this manuscript were obtained without any restriction and provided as a “supportive file” in the web application.

4. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #2: No

Author response: Thank you, we accept your comments. Typographical and grammatical errors in the revised manuscript were corrected and made to be clear.

5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: Major comments

Title

You are using two terms (time and early) with similar meanings. I would suggest removing either of them. The title is not clearly stated. I suggest: Early breastfeeding cessation and its predictors among mothers with two to three years old children in Gozamin....

Author response: Accepted and modified as the time to breastfeeding cessation and its predictors among mothers who have children aged two to three years in Gozamin district, Northwest Ethiopia. As we all know the title should be precise, predictive, and well explanatory, which means that a title should have a minimum word that at least tell the nature of the outcome variable, the type of statistical model, and the design that will use. If we made the title “early breastfeeding cessation and its predictors……”, it tells us logistic regression and cross-sectional study design were used. Hence it was modified as “time to breastfeeding cessation and its predictors……”. In this case, it indicates that the outcome variable is “time to event” and hence the statistical modeling used was “survival analysis”.

Corresponding author: No need to mention these details here, put the adress next to your address above. To show the corresponding author, put * next to the name then mention what the * means. * Corresponding author

Author response: Accepted and corrected accordingly in the revised manuscript.

Abstract: What is the importance of mentioning the last sentence in the introduction? Delete it and add the aim/objective of your study

Author response: last two sentences in the introduction part of the abstract conclude that both statement of the problem and the objective of the study in a precise way. Of course, we modified it by adding the objective of the study in the revised manuscript to be more clear and attractive according to the journal requirement.

Methods (page 5)

I do not think that the you have used proper study design

Author response: The study aimed to detect the incidence of early breastfeeding cessation before the WHO recommendation and time to this cessation. For this purpose, we followed birth cohorts retrospectively they were born for the last two years with certain exposure statuses mentioned as variables. We identified mothers who have children aged two to three years of age and we took their exposure status and then we followed them until the outcome variable happened (time to breastfeeding cessation or the WHO recommended time=time to event or time to censoring as operationalized in the operational definition) by recalling of the mother and the records found at the Health post. Hence, a retrospective follow-up study was used in this way.

You have explained too much about study area which is less important, try to summarize in few sentences.

Author response: Thank you, accepted; and summarized accordingly in the revised manuscript.

What is your justification to take this timeframe October 2017 to September 20202?

Author response: This study was started at the end of September 2020. To follow mothers for two years (Follow up period), a one-year birth cohort was recruited (recruitment period). So the recruitment period started from October 1/2017 up to September 30/ 2018, and then we followed them from October 1/2018 up to September 30/2020, which was the follow-up period. That is why this time frame was taken.

The inclusion criteria is similar with the study population, try to summarize the subheadings and avoid repetition.

Author response: in the revised manuscript repetition was corrected and summarized within the single subheading as we accept your recommendation.

Exclusion criteria (last two lines), Not clear what you want to say? revise it

Author response: “Mothers who have not initially breastfed at least once for the child age two to three years now, and who gave care and breastfed other than their child” are the last two sentences in the exclusion criteria. Mothers who didn’t start breastfeeding for the child were excluded because they have no survival time (no breastfeeding duration). In the rural part of the Ethiopian context, some mothers care and breastfeed other than their own child, for example those children whose mothers were died may breastfeed the neighboring mothers breast milk and care by them. Such mothers were excluded from this study because we may not get the full survival time or censoring time during the follow-up time.

Sampling procedure: What is the total number of Kebele, from how much did you select ten?

Author response: There are 30 kebeles in the study area and 30% of the kebeles were taken randomly. Statistically, if 20% to 30% of the population were taken using the probability sampling technique, representativeness was maintained.

Why do you use the word "infant chaild pairs" Have you collect any data from the child? I would suggest to use mothers....

Author response: For this study, participants were Mother-child pairs because in our context some mothers become pregnant and give birth even within one year of the child. In this case, the mother should be paired with the older child whose age was two to three years, otherwise, they give a response to the latest child. To avoid confusion for the data collectors and participants, mother-child pairs were used.

data collection: I do not know why you have taken date of birth as starting point? it is obvious. Your dependent variable is early BF cessation before 24 months and the participants are mothers with children 2-3 years. So why are you using retrospective follow up design? which is used to assess the outcome of certain exposure. I think the design you have used is not correct. I am ready to hear your explanation about this. The last three lines of page 8: To answer this, why do you use retrospective follow up? because it is obvious that they have started after birth then stopped in one specific time.

Author response: The dependent variable is “time to breastfeeding cessation” not only early breastfeeding cessation. The study aims to detect the survival time of breastfeeding up to WHO recommendation. So, to get the survival time the starting point of follow-up was birth (breastfeeding starts immediately after birth, nearly 30 minutes) and followed mother-child pairs until event or censoring. The exposure variables were identified during birth and then follow mother-child pairs until event or censoring. That is why a retrospective follow-up study design was used.

Data collection tool: This should come before data collection. I would suggest to merge with the above sub headings. What was the findings of your pretest, summarize in one or two sentences? was there any problem with the tool? what do you find from your pretest?

Author response: As per your recommendation, subheadings (Data collection procedures and data collection tools) were merged as Data collection tools and procedures in the revised manuscript. Findings of pretest were summarized in the revised manuscript as “not easily understandable questionnaires’ were modified and some variables missed during pretest were incorporated in the final questionnaires”.

Results

First sub title: Why are you referring as baseline? it is confusing. do you have any data taken during follow up? I think such category is used for multiphase study but yours is single phase study. Therefore, better to sat Sociodemographic characteristics

Fourth line of first sub heading: Did you had any follow up time in your study? I this the main problem is related to the study design. What is the importance of mentioning this as incidence?

Author response: In this study, initially we took baseline maternal characteristics such as educational status, marital status, age, etc. of the mother at childbirth, and even if it is not a fully multi-phasing study, we took follow up data from the mother and other records such as immunization certificate, starting time of complementary feeding, presence of cow milk at home at least for the last two seasons. We didn’t take further sociodemographic characteristics after birth. Due to this “baseline sociodemographic characteristics” were used as a subheading. Another point you raised was “follow-up time”. It is a follow-up study from birth up to date of breastfeeding cessation or censoring time to get the survival time of breastfeeding duration. By this follow-up time, the new occurrence of breastfeeding cessation was counted and calculated the incidence rate of breastfeeding cessation before the WHO recommendation time. That is why “incidence” was written in the manuscript.

Minor comments

Title page: Be consistent, you have added affiliation to 2 and 3 but 1 and 4 did not have affiliation. Put each email next to their address

Author response: as per comments the title page consistency was revised (see the revised manuscript with track change).

Abstract: add comma to 14000, in the conclusion you have used different line spacing

data collection procedure there is a word "For 4 data collectors.... What? not clear

There are grammatical errors, the language need revision

Author response: all minor comments in the initial manuscript were modified in the revised manuscript including grammatical and language errors. For “4 data collectors” means that for interviewing mother-child pairs 2 B.Sc. nurses and 2 Health officers were involved, a total of four data collectors for this purpose. It is revised.

Reviewer #2: The draft manuscript should convince clearly with evidence the breastfeeding cessation is a critical issue in Ethiopia. Otherwise, the analyses objective should be revised to be appropriated with the country evidence-based breastfeeding issue. There is a need for the study to develop a theory of what factors and their mechanisms to predicting the breastfeeding behaviour. The arguments provided in the background is often inconsistent (See my attached written review).

Author response: Dear reviewer #2, thank you for your valuable comments and your devotion of time to this manuscript to be a full scientific paper. All scientific papers distributed to the scientific community should convince readers and be part of the solution for the problem identified in the research. This study identified that breastfeeding cessation before the WHO recommendation time was a problem that leads to 14000 childhood deaths and 5 million diarrheal and pneumonia cases annually in Ethiopia. As you explained, it is not only due to exclusive breastfeeding cessation but includes breastfeeding cessation later to 6 months that caused this problem. The proportion of Breastfeeding cessation before WHO recommended duration was less than in Ethiopia as compared to the overall sub-Saharan African countries, but the duration of breastfeeding in Ethiopia was in a decreasing trend from 2005 EDHS to 2016 EDHS (92%to 85% to 76%) with regional variation (EDHS 2016). This increased the health care costs of Ethiopia up to 0.003% GNI of the country. So that identifying whether breastfeeding cessation timing was a problem or not specifically in the rural part of Northwest Ethiopia has paramount importance. Another issue you raised is that “there is no conceptual framework of factors how that cause timing variation in breastfeeding cessation”. The original draft of this study has a conceptual framework that shows the relation between independent variables with the dependent variable, but it is not attached in the manuscript due to the journal requirement. (For further, you can see below)

Conceptual framework

6. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: No

Reviewer #2: No

Author response: No

[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.]

While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step.

Submitted filename: Response to Reviewers.docx

Click here for additional data file.

7 Dec 2021

9 Dec 2021

Author Feedback: Dear editors and reviewers of this manuscript, we have no sufficient words to give our gratitude for your devotion of time and energy to improve the manuscript sufficient enough to be ready for production and then publication. As per your comments, we have tried to improve the manuscript and gave responses to those comments one by one. Dear editors and reviewers, even further we are ready to hear your comments and improve accordingly. Thanks a lot.

[Note: HTML markup is below. Please do not edit.]

Editors’ comments: Thank you for addressing the reviewers' comments and suggestions. However, I cannot recommend acceptance of the manuscript yet because your marked-up copy of the revised version does not have track changes on it, which makes it difficult to compare the changes you have made against the original draft. Therefore, please resubmit the revised version with track changes on. Further, please also insert the conceptual framework in the text so that I can have it reviewed.

Authors' response: Thank you for your valuable comments and suggestions. As per your comments, we have tried to add a copy of the marked up or tracked change manuscript. Besides, we have added a conceptual framework on the manuscript with a brief text form and the full form is attached as figure -1 (Further see page 4 paragraph 2 of the manuscript).

Reviewers' comments:

Reviewer #2: The draft manuscript should convince clearly with evidence the breastfeeding cessation is a critical issue in Ethiopia. Otherwise, the analyses objective should be revised to be appropriated with the country evidence-based breastfeeding issue. There is a need for the study to develop a theory of what factors and their mechanisms to predicting the breastfeeding behaviour. The arguments provided in the background is often inconsistent (See my attached written review).

Author response: Dear reviewer #2, thank you for your valuable comments and your devotion of time to this manuscript to be a full scientific paper. All scientific papers distributed to the scientific community should convince readers and be part of the solution for the problem identified in the research. This study identified that breastfeeding cessation before the WHO recommendation time was a problem that leads to 14000 childhood deaths and 5 million diarrheal and pneumonia cases annually in Ethiopia. As you explained, it is not only due to exclusive breastfeeding cessation but includes breastfeeding cessation later to 6 months that caused this problem. The proportion of Breastfeeding cessation before WHO recommended duration was less than in Ethiopia as compared to the overall sub-Saharan African countries, but the duration of breastfeeding in Ethiopia was in a decreasing trend from 2005 EDHS to 2016 EDHS (92%to 85% to 76%) with regional variation (EDHS 2016). This increased the health care costs of Ethiopia up to 0.003% GNI of the country. So that identifying whether breastfeeding cessation timing was a problem or not specifically in the rural part of Northwest Ethiopia has paramount importance. Another issue you raised is that “there is no conceptual framework of factors how that cause timing variation in breastfeeding cessation”. The original draft of this study has a conceptual framework that shows the relation between independent variables with the dependent variable. Now, it is attached in the manuscript as per your comments. (For further, you can see at the manuscript-page 4 paragraph 2 and figure 1).

[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.] While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step.

Submitted filename: Response to Reviewers.docx

Click here for additional data file.

14 Dec 2021

17 Dec 2021

Author Feedback: Dear editors and reviewers of this manuscript, we have no sufficient words to give our gratitude for your devotion of time and energy to improve the manuscript sufficient enough to be ready for production and then publication. As per your comments, we have tried to improve the manuscript and gave responses to those comments one by one. Dear editors and reviewers, even further we are ready to hear your comments and improve accordingly. Thanks a lot.

[Note: HTML markup is below. Please do not edit.]

Editors’ comments: Thank you for addressing the reviewers' comments and suggestions. However, I cannot recommend acceptance of the manuscript yet because your marked-up copy of the revised version does not have track changes on it, which makes it difficult to compare the changes you have made against the original draft. Therefore, please resubmit the revised version with track changes on. Further, please also insert the conceptual framework in the text so that I can have it reviewed.

Authors' response: Thank you for your valuable comments and suggestions. As per your comments, we have tried to add a copy of the marked up or tracked change manuscript. Besides, we have added a conceptual framework on the manuscript with a brief text form and the full form is attached as figure -1 (Further see page 4 paragraph 2 of the manuscript).

Reviewers' comments:

Reviewer #2: The draft manuscript should convince clearly with evidence the breastfeeding cessation is a critical issue in Ethiopia. Otherwise, the analyses objective should be revised to be appropriated with the country evidence-based breastfeeding issue. There is a need for the study to develop a theory of what factors and their mechanisms to predicting the breastfeeding behaviour. The arguments provided in the background is often inconsistent (See my attached written review).

Author response: Dear reviewer #2, thank you for your valuable comments and your devotion of time to this manuscript to be a full scientific paper. All scientific papers distributed to the scientific community should convince readers and be part of the solution for the problem identified in the research. This study identified that breastfeeding cessation before the WHO recommendation time was a problem that leads to 14000 childhood deaths and 5 million diarrheal and pneumonia cases annually in Ethiopia. As you explained, it is not only due to exclusive breastfeeding cessation but includes breastfeeding cessation later to 6 months that caused this problem. The proportion of Breastfeeding cessation before WHO recommended duration was less than in Ethiopia as compared to the overall sub-Saharan African countries, but the duration of breastfeeding in Ethiopia was in a decreasing trend from 2005 EDHS to 2016 EDHS (92%to 85% to 76%) with regional variation (EDHS 2016). This increased the health care costs of Ethiopia up to 0.003% GNI of the country. So that identifying whether breastfeeding cessation timing was a problem or not specifically in the rural part of Northwest Ethiopia has paramount importance. Another issue you raised is that “there is no conceptual framework of factors how that cause timing variation in breastfeeding cessation”. The original draft of this study has a conceptual framework that shows the relation between independent variables with the dependent variable. Now, it is attached in the manuscript as per your comments. (For further, you can see at the manuscript-page 4 paragraph 2 and figure 1).

[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.] While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step.

Submitted filename: Response to Reviewers.docx

Click here for additional data file.

26 Dec 2021

28 Dec 2021

Response to Reviewers

Author Feedback: Dear editors and reviewers of this manuscript, we have no sufficient words to give our gratitude for your devotion of time and energy to improve the manuscript sufficient enough to be ready for production and then publication. As per your comments, we have tried to improve the manuscript and gave responses to those comments one by one. Dear editors and reviewers, even further we are ready to hear your comments and improve accordingly. Thanks a lot.

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Editors’ comments: Thank you for uploading the revised manuscript with track changes on, which has made it possible for me to compare your responses with the reviewers' comments. However, minor editorial omissions continue to remain in Revision#3. For example, in the Introduction to the Abstract you have cited the number 14000 without a comma as a ,000 separator. Please write the number as 14,000. Similarly, in Methods in the Abstract you have started the sentence with a lower case "a" such as "a community-based retrospective follow-up study was used...." . This should be written as "A community-based retrospective follow-up study was used....". (i.e. beginning with an upper case "A"). PLOS One does not provide copy editing, therefore please make the corrections as indicated above, and have the entire revised manuscript thoroughly edited for English.

Authors' response: Thank you for your valuable comments and suggestions. As per your comments, we have tried to improve typological and grammatical problems on the revised manuscript.

Submitted filename: Response to Reviewers.docx

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30 Dec 2021

Time to breastfeeding cessation and its predictors among mothers who have children aged two to three years in Gozamin district, Northwest Ethiopia: a retrospective follow-up study

PONE-D-21-09209R4

Dear Tilahun Degu Tsega

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Gouranga Lal Dasvarma, PhD

Academic Editor

PLOS ONE

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Reviewers' comments:

11 Jan 2022

PONE-D-21-09209R4

Time to breastfeeding cessation and its predictors among mothers who have children aged two to three years in Gozamin district, Northwest Ethiopia: a retrospective follow-up study

Dear Dr. Tsega:

I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now with our production department.

If your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information please contact onepress@plos.org.

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on behalf of

Dr. Gouranga Lal Dasvarma

Academic Editor

PLOS ONE