Formula feeding practices and associated factors among neonates in public hospital neonatal intensive care units in Bahir Dar Ethiopia

Abstract The practice of feeding formula milk to infants less than six months, can significantly increase infant mortality and lead to various diseases. Evidence on formula-feeding practices among neonates admitted to neonatal intensive care units (NICUs) in Ethiopia is limited, and community estimates may not describe this clinically vulnerable population. This study aimed to assess formula feeding practices and their associated factors among neonates admitted to the Neonatal Intensive Care Unit of public hospitals in Bahir Dar City, Northwest Ethiopia, in 2022. We conducted a convergent parallel mixed-methods study from 30 November to 30 December 2022. Quantitatively, 331 mothers of neonates aged 0–28 days were selected using systematic sampling from three public-hospital NICUs. Qualitatively, five mothers from urban areas and five NICU nurses were purposively selected for in-depth and key-informant interviews. Quantitative data were collected using a structured interviewer-administered questionnaire and analyzed in SPSS version 25 using binary logistic regression. Variables with p < 0.20 in bi-variable analysis were entered into the multivariable model; p < 0.05 was considered statistically significant. Qualitative data were analyzed inductively using a reflexive thematic approach and integrated with the quantitative findings. Formula feeding practice was reported for 124 of 331 neonates (37.5%; 95% CI 32.0–43.2); 64 (19.4%) were exclusively formula-fed and 60 (18.1%) received both formula and breast milk. In the adjusted model, formula feeding was associated with cesarean delivery (AOR, 4.09; 95% CI 1.47–11.37), no breastfeeding counseling after delivery (AOR, 3.11; 95% CI 1.43–6.76), information about formula milk (AOR, 5.86; 95% CI 2.73–12.56), low versus high knowledge (AOR, 3.00; 95% CI 1.22–7.36), and neutral (AOR, 2.32; 95% CI 1.08–4.96) or positive (AOR, 4.25; 95% CI 1.70–10.60) attitude toward formula feeding. Qualitative findings indicated that insufficient perceived milk, maternal illness or postoperative discomfort, formula availability and promotion, and gaps in facility-based counseling shaped feeding decisions. Formula feeding practice was common in this NICU-admitted sample. The observed associations should be interpreted cautiously, as the cross-sectional design does not establish temporal or causal relationships. Strengthening context-appropriate breastfeeding counseling, particularly after cesarean delivery and when direct breastfeeding is difficult, may help facilities support mothers to provide breast milk when clinically feasible.