Geographic variations and factors associated with breastfeeding counseling during the first 2 days of birth in Ethiopia: spatial and multilevel analysis

Breastfeeding improves child health, and counseling during pregnancy and after delivery supports early initiation and exclusive breastfeeding. However, coverage remains uneven in many low- and middle-income countries, and relatively little work has sought to use multilevel and spatial variability. Therefore, this study aimed to assess geographical variations and individual- and community-level determinants of breastfeeding counseling in Ethiopia. A secondary data analysis was conducted on 3,979 mothers using the 2019 Ethiopian Mini Demographic and Health Survey. Global Moran’s I and Getis-Ord Gi* statistics were used to identify clustering and hotspot areas, while SaTScan was applied to detect statistically significant clusters. Multilevel logistic regression was then used to examine the associations between breastfeeding counseling and its determinants. Adjusted odds ratios (AORs) with 95% confidence intervals were estimated after adjusting for both individual-level variables (socio-demographic, infant and obstetric related variables) and community-level variables (aggregated from individuals). The overall coverage of breastfeeding counseling within 48 h of postpartum was 39.6% (95% CI: 38.06%-41.10%) with marked regional disparities. The highest coverage was observed in Addis Ababa, Bahir Dar, Assosa, central Gambella, and northern SNNP, whereas the lowest coverage was observed in eastern SNNP, northern Somali, and southeastern Gambella. Mothers delivering in health institutions- (AOR = 5.20; 95% CI: 1.68–16.06), receiving postnatal checkups before discharge (AOR = 2.46; 95% CI: 1.51–4.00), and residing in communities with high antenatal care coverage (AOR = 2.12; 95% CI: 1.10–4.07) significantly increased the likelihood of receiving breastfeeding counseling. Breastfeeding counseling coverage in Ethiopia is low with substantial regional inequalities, particularly poor access in the Somali, SNNP, and Gambella regions. Women were more likely to receive breastfeeding counseling when they delivered in health facilities, had postnatal checkups before discharge, and lived in communities with high antenatal care coverage. Integrating standardized breastfeeding counseling into all facility-based deliveries and postnatal contacts alongside targeted outreach services is recommended for low-performing regions.