Factors Affecting Exclusive Breastfeeding Practice Among Nursing Mothers

Factors Affecting Exclusive Breastfeeding Practice Among Nursing Mothers

Abstract

The health benefits of exclusive breastfeeding on survival, growth and development of a child as well as health and wellbeing of a mother are well documented. Factors influencing breastfeeding have been well researched but there is paucity of data on factors influencing exclusive breastfeeding practices. This study aimed to establish the prevalence and identify the factors influencing the practice of exclusive breastfeeding among infants in an urban slum in a rural area. This community based cross sectional analytical study was carried out in Uyo Local Government Area in Akwa Ibom state, Nigeria among 171 randomly selected mothers with infants less than 6 months old. Data were collected using researcher-administered questionnaires and a focus group discussion guide. Six focus group discussions were held at the end of the study with traditional birth attendants, grandmothers, fathers, mothers practicing and those not practicing exclusive breastfeeding. The dependent variable was exclusive breastfeeding rate defined as continuous exclusive breastfeeding since birth and exclusive breastfeeding based on 24 hour-recalls. Data analysis was done using statistical package for social sciences (SPSS) software version 17.0. The rate of continuous exclusive breastfeeding since birth was 38.0% (95% CI; 30.7-45.3) while the rate based on 24 hour recall was 56.7% (95% CI; 49.3-64.2).

In univariate analyses, infant age and infant morbidity, maternal morbidity, maternal breast health and maternal knowledge on breastfeeding issues had significant associations with exclusive breastfeeding. Maternal knowledge aspects included; mothers correct knowledge on duration of exclusive breastfeeding (Odds Ratio [OR]: 2.61; 95% CI: 1.345-5.069; P=0.005) and OR: 3.418; 95% CI: 1.807-6.465; P<0.001); maternal knowledge that breastfeeding protects the mother from getting pregnant (OR: 2.092; 95% CI: 1.072-4.084; P=0.030) and (OR: 1.445; 95% CI: 0.755-2.767; P=0.266) and mothers knowledge that semi-solid/solid foods should be introduced to the infants at six months of age (OR: 2.683; 95% CI: 1.142-6.306; P=0.024) and (OR: 3.102; 95% CI: 1.4506.634; P=0.004). In the logistic regression analyses, infant morbidity (Adjusted Odds Ratio [AOR]: 2.45, 95% CI: 1.23-5.08, P=0.01) for continuous EBF since birth and (AOR: 3.94, 95% CI: 1.90-8.20, P=<0.01) for EBF based on 24 hour recall was retained as the strongest predictor of exclusive breastfeeding. Mother’s experience of breastfeeding complications (AOR: 2.42, 95% CI: 0.98-5.97, P=0.05 and (AOR: 2.67, 95% CI: 1.89-6.01, P=0.02) was the second predictor of exclusive breastfeeding having controlled for age of child. Exclusive breastfeeding rate in Uyo Local Government Area was below the level recommended by WHO (90%) although higher than the Nigeria national rate (32%).

The study findings indicated that infant morbidity and maternal breast health are important factors to consider in the messages on the promotion of exclusive breastfeeding as they are critical for its practice. Negative attitudes and beliefs on exclusive breastfeeding should be addressed as they also affect exclusive breastfeeding. Additionally, there is need to improve on strategies, education and training on information concerning exclusive breastfeeding in order to reach mothers with low knowledge on the benefits and optimal duration of exclusive breastfeeding. Ministry of Public Health and Sanitation should review the implementation of BFHI in the health facilities.

Table Of Contents

Preliminary Page(s)

• Title page i
• Certification page ii
• Dedication iii
• Acknowledgement iv
• Abstract v
• Table of content

Chapter One:

Introduction

• 1.1 Background information
• 1.2 Problem statement and justification
• 1.3 Purpose of the study
• 1.4 Objectives of the study
• 1.5 Hypothesis
• 1.6 Significance of the study
• 1.7 Delimitation of the study
• 1.8 Limitations of the study
• 1.9 Conceptual framework for the study
• 1.10 Operational definition of terms

Chapter Two:

Review Of Related Literature

• 2.1 Benefits of breastfeeding to the infant
• 2.2 Benefits of breastfeeding to the mother
• 2.3 Benefits of exclusive breastfeeding
• 2.4 Global picture on status of exclusive breastfeeding
• 2.5 Status of exclusive breastfeeding in Nigeria
• 2.6 Factors influencing the practice of exclusive breastfeeding
• 2.7 Promotion, support and protection of breastfeeding
• 2.8 Summary of literature review

Chapter Three:

Research Methodology

• 3.1 Research design
• 3.2 Variables
• 3.3 Study location
• 3.4 Target population
• 3.5 Sampling techniques
• 3.6 Sample size determination
• 3.7 Research instruments
• 3.8 Selection and training of research assistants
• 3.9 Data collection techniques
• 3.10 Data analysis

Chapter Four:

Results And Discussion

• 4.1 Characteristics of the study population
• 4.2 Delivery history of the mother
• 4.3 Maternal health characteristics
• 4.4 Infant characteristics
• 4.5 Feeding practices among infants 0<6 months old in Uyo Local Government Area
• 4.6 Maternal knowledge on breastfeeding issues
• 4.7 Attitudes/perceptions and beliefs on breastfeeding
• 4.8 Factors associated with exclusive breastfeeding practices

Chapter Five:

Summary, Conclusions And Recommendations

• 5.1 Summary of findings
• 5.2 Conclusions
• 5.3 Recommendations
• References
• Appendix
• Questionnaire

Chapter One

Introduction

1.1 Background information

Breastfeeding is unequaled way of providing ideal food for the health, growth and development of infants and most natural way of feeding them in all traditions. It is an integral part of the reproductive process with important implications for the health of the mother. Human milk is the most appropriate of all available types of milk, that is uniquely adapted for infant nutrition as it components consistently adopt to the child’s need and environmental challenges. Breast milk contains virtually all the nutrients antibodies and anti-oxidants an infant needs to thrive for the first six months of life (Abasiattai, Umana, Nyong and Eyo, 2014).

The benefits of breast feeding for mothers and infants have been widely recognized and researched studies have shown that breastfeeding is superior to infant formula feeding because of its protective properties against illness, in addition to its nutritional advantages (Sadoh, Oniyelu, 2011). Considering the extensive benefits of breastfeeding, the world Health organization and the American Dietetic Association recommended exclusive breast feeding of infants for the first six months and continued breastfeeding with complementary foods up to twelve (12) months of age (ADA Report, 2001). Despite widespread efforts to encourage breastfeeding, the rates in the United States (U.S) have remained low (Pugh, 2002).

Exclusive breastfeeding (EBF) refers to the exclusive intake of breast milk or expressed breast milk by an infant without the addition of any other liquid or solids, with the exception of oral drops or syrups containing vitamins, mineral supplements or medicines. Exclusive breastfeeding advocated the world over as the optimal mode of feeding for young infants in the first months of life, followed by breast milk and complimentary feeds thereafter till two years of age or beyond. When the infants are exclusively breastfed for the first six months of life, their immune system is stimulated and this goes hand in hand with protecting them from disease like diarrhea and acute respiratory infections, which are considered to be two of the major causes of infant mortality in developing world. When breastfeeding is practiced exclusively, it is associated with a lower risk of HIV transmission than mixed feeding.

Other advantages of exclusive breastfeeding include reduction in post partum bleeding, improvement in home status later in life and protection against breast and ovarian cancers. Other benefits include lactational amenorrhea which enhances child spacing, early mother-infant bonding and reduction in infant abandonment and child abuse. EBF also provides social and economic benefits to the family and the nation as well as a sense of satisfaction to most nursing-mothers (Madhu, Chowdary and Masti, 2009).

Breastfeeding is accepted as the natural form of infant feeding. For mothers to be able to breastfeed exclusively to the recommended six months, it is important to understand the factors that affect exclusive breastfeeding, studies of non pregnant high school students suggest that attitudes toward infant feeding begin to form well before pregnancy. Previous research has shown that maternal attitudes toward breastfeeding and perceptions of infant health benefits of breastfeeding influence the decision of breastfeed. Man demographic factors such as maternal age, marital status, education, race, nature of work, cultural factors, parity number of children at home and social support, urban versus rural residence and employment policies have been shown to potentially affect a nursing-mother’s decision (Dubois, Girard, 2003).

Among all of these factors, mother’s education had greater impact on nutritional status of children. However, it does not mean that mothers with high education level had healthy children only. Many studies outside the south-south region and very few within the region have been carried out to ascertain most factors that affect exclusive breastfeeding practices among nursing mothers. For instance, Tan (2011) researched on factors associated with exclusive breastfeeding among infant under six months of age in Peninsular Malaysia, he found that the prevalence of exclusive breastfeeding among mothers with infant aged between one and six months was one percent (Abasiattai et al, 2014). In the study on knowledge and practice of exclusive breast-feeding among antenatal attendees in Uyo, southern Nigeria revealed that the level of knowledge and practice of exclusive breastfeeding by women in Uyo is poor and as such none of the women belonged to a breastfeeding support group and the most common source of information on exclusive breastfeeding was the antenatal health talk.

Other efforts made toward the determination of factors affecting exclusive breastfeeding practices among nursing mothers are the works of Setegn, Belachew, Gerbaba, Deribe, Denshaw and Biadgilign (2012) on factors associated with exclusive breastfeeding practices among mothers in GobaArea, discovered that the prevalence of exclusive breastfeeding for infant aged less than six months in the study area was 71-3 percent as measured by last 24 hours recalled period preceding the survey date.

A critical examination of the above cited study by different authors and researchers show that there is no consistency to ascertain to which extent the factors mentioned above affect exclusive breastfeeding practices among nursing-mothers and which of the factors has the prevalence effects or influence.

The researcher in the current study is interested to investigate the effect of educational level, nature of work and the mother’s age on the practices of exclusive breastfeeding among nursing-mothers in Uyo Local Government Area in Akwa Ibom State.

1.2 Problem statement and justification

Poor knowledge and attitudes of nursing-mothers toward breastfeeding has generated a lot of controversy in our modern society, influence practices and constitute barriers to optimizing the benefits of the Baby friendly initiative (BFI) aims to provide a supportive environment for breast-feeding and also encourages mothers to know and practice the ten steps to clinics (Abasiattai et al., 2014).

Despite the known benefits of exclusive breastfeeding to nursing mothers and infants based on anecdotal and empirical evidence, which the World Health Organisation (WHO) has recommended 2 years breastfeeding. First 6 months exclusive breastfeeding; more than 8 times breastfeeding of the baby for day in the first 3 months of the infants life. The attitude of most nursing-mothers of the infant’s life. The attitude of most nursing-mothers is a reverse of this recommendation WHO/UNICEF Article February 2nd, 2014).

Studies have revealed that most nursing-mothers in the urban area denied their babies exclusive breastfeeding up to four months from birth, and that most of the highly socio-economic status nursing mothers have not exclusively breastfed their babies. Moreover, it is observed that most poor nursing-mothers especially in the rural areas over exclusively breastfed their babies beyond six months and over two years of breastfeeding infants. The unequal situations have posed a lot of questions to medical health scholars and health researchers against which factors are responsible or militate against these attitudes of nursing-mother toward exclusive breastfeeding.

However, a gamut of factors not limited to race and cultural characteristics, infant health problems, socio-economic status and some psychosocial factors may hamper the full realization of the baby friend initiative and also information about the beliefs and knowledge that may constitute barriers and in turn affect practices needed in order to optimally utilize the benefits of the baby friendly initiative. Consequently, a number of studies have assessed knowledge, attitude and practice of breastfeeding in different parts of the world, states and local governments. However, such studies are not limited to nursing-mothers in Uyo Local Government Area.
Against the above premise the study investigated the factors affecting exclusive breastfeeding practice among nursing-mothers in Uyo local government area of Akwa Ibom State.

1.3 Purpose of the study

The aim of the study was to investigate the factors affecting exclusive breastfeeding practice among nursing mothers of infants 0 < 6 months in Uyo Local Government Area.

1.4 Objectives of the study

The objectives of this study were to;

1. Establish socio-demographic, socio-economic characteristics and contextual factors of mother with infants 0<6 months old in Uyo Local Government AreaAkwa Ibom state.
2. Determine the characteristics of infants 0<6months in Uyo informal settlement Akwa Ibom state.
3. Determine the prevalence of exclusive breastfeeding among infants 0 < 6 months old in Uyo Local Government AreaAkwa Ibom state.
4. Establish maternal knowledge, attitudes and beliefs on exclusive breastfeeding in
   Uyo Local Government Area Akwa Ibom state.
5. Establish the factors associated with exclusive breastfeeding in Uyo Local Government AreaAkwa Ibom state.

1.5 Hypothesis

HO1: The prevalence of exclusive breastfeeding for infants 0 < 6 months old inUyo Local Government Area is significantly lower than the WHO recommended level of ninety percent (90%).

HO2: Infant characteristics (age, sex and morbidity) have no significant association with exclusive breastfeeding practice of infants 0<6 months old in Uyo Local Government Area.

HO3: Maternal characteristics and contextual factors have no significant associations with the practice of exclusive breastfeeding of infants 0< 6 months old in Uyo Local Government Area.

HO4: Maternal knowledge, attitudes and beliefs have no significant associations with the practice of exclusive breastfeeding of infants 0< 6 months old in Uyo Local Government Area.

1.6 Significance of the study

This study has generated information on factors influencing exclusive breastfeeding practices in a poor-resource setting. The findings will be useful to the Ministry of Public Health and Sanitation (MOPHS) and other organizations working in child survival programmes to design interventions to improve the practice of exclusive breastfeeding in the area and other similar circumstances. The findings will also be useful as a contribution to the ongoing research efforts on exclusive breastfeeding and child survival.

1.7 Delimitation of the study

The study was only carried out in Uyo Local Government Area, an urban slum in a rural area. The results can only be generalized to other areas with similar characteristics.

1.8 Limitations of the study

The study being cross-sectional, data collected did not reveal whether the reported infant feeding practices varied from one day to another.

1.9 Conceptual framework for the study

This study adopted Ochola’s conceptual framework (Figure 1.1) on factors associated with exclusive breastfeeding practices (Ochola, 2008).

Figure 1.1: Conceptual Framework on factors associated with breastfeeding practices.

Source: Adapted fromOchola (2008).

Breastfeeding is a complex process governed by psychological and physiological factors which are in turn conditioned by a wide spectrum of environmental, socio-economic and cultural factors (Obermeyer and Castle, 1997). These factors affect breastfeeding and exclusive breastfeeding rates in different directions and to varying degrees depending on culture (Aidamet al., 2005). While there is a large body of published material on the factors affecting breastfeeding, there are few studies documenting factors influencing exclusive breastfeeding. A fundamental limitation of research in this area is lack of a conceptual or theoretical base to guide researchers in planning their studies or to assist readers to interpret results in a broad context (Hector, King and Web, 2005).

Furthermore there are limited studies especially in Nigeria that have investigated the factors associated with exclusive breastfeeding. For this study, the framework was used as a guide to investigate the maternal demographic characteristics (education, age and marital status), knowledge on breastfeeding, maternal morbidity, socio-economic factors (occupation, income source and item ownership) and contextual factors (place of delivery, type of delivery, breastfeeding support (breastfeeding counseling and sources of information) and attitudes and beliefs about breastfeeding practices.

1.10 Operational definition of terms

Appropriate health seeking behavior-

Seeking prompt and appropriate care and treatment for illnesses

Contextual factors

Place of child delivery, type of child delivery, breastfeeding support from family and breastfeeding support programmes/counseling.

Cultural factors

Population beliefs, norms and local myths about breastfeeding and infant feeding practices.
Exclusive breastfeeding-this means an infant is fed only on breast milk (including milk expressed from a wet nurse) and allows for medicine, oral rehydration, drops or syrups (vitamins and syrups) (WHO, 2008).

Informal settlement / slum

Living conditions in which a household lacks one or more of these conditions; access to improved water, access to improved sanitation facilities, sufficient living area-not overcrowded, structural quality/durability of dwellings and security of tenure (World Bank, 2008).

Maternal factors

Education, knowledge on breastfeeding, morbidity and breast health. Socio-economic factors – defined byincome, occupation and proxy indicators such as ownership of items.

Partial breastfeeding

An infant receives breast milk and any food or liquids including non-human milk and formula (WHO, 2008).

Predominant breastfeeding

An infant receives breast milk (including milk expressed from a wet nurse) as the predominant source of nourishment and allows water and waterbased drinks, fruit juice, ritual fluids, oral rehydration salts, drops or syrups (vitamins, minerals and medicine) (WHO, 2008).

Pre-lacteal foods

Non-breast milk feeds given before breastfeeding is initiated (WHO, 2008).

Post –lacteal feeds

Non-breast milk fluids and foods given after breastfeeding has been initiated

Chapter Five

Summary, Conclusions And Recommendations

5.1 Summary of findings

This study was a community based cross sectional study aimed at establishing the prevalence and identifying the factors that influence exclusive breastfeeding practice among infants 0<6 months old in Uyo Local Government Area in Akwa Ibom state. Quantitative data was collected using researcher-administered questionnaires while qualitative data were collected from focus group discussions to elicit information on the attitudes/perceptions and beliefs on exclusive breastfeeding.

The rate of continuous exclusive breastfeeding since birth was 38% while the rate of exclusive breastfeeding based on 24 hour recall was 56.7% in the study area. The difference in the two rates implies that although many mothers initiate exclusive breastfeeding, it is only a small percentage of the mothers that adhere to the practice for the recommended duration of the first six months of an infant’s life. Following the findings on the low rate of exclusive breastfeeding in the study area, the hypothesis that the prevalence of exclusive breastfeeding in Uyo Local Government Area is significantly lower than the level recommended by World Health Organization of 90% was not
rejected.

In this study, results of the univariate analysis showed that maternal morbidity and breastfeeding complications, maternal knowledge and infant age and morbidity had significant associations with exclusive breastfeeding. Maternal socio-demographic, socio- economic and contextual factors had no significant association with exclusive breastfeeding. Maternal morbidity and presence of breastfeeding complications were negatively associated with exclusive breastfeeding. The implication of this finding is that mothers need to be counseled on how to deal with their health conditions so as not to interfere with exclusive breastfeeding.

Mothers who had correct knowledge on duration of exclusive breastfeeding, knowledge that semisolid/solid food should be introduced at six months and knowledge that breastfeeding delays pregnancy were more likely to practice exclusive breastfeeding. This finding confirms that maternal knowledge on breastfeeding and infant feeding practices is critical to appropriate infant feeding practices.

Advanced infant age and presence of infant morbidly were negatively associated with exclusive breastfeeding. The implication of this finding is that mothers should be counseled on the need to seek prompt and appropriate care for seek infants in order to ensure infant feeding is not affected as well as prevent mortality. Additionally, negative attitudes and beliefs affect exclusive breastfeeding negatively and it is imperative that they should be addressed. In the logistic regression, the greatest predictor of exclusive breastfeeding was infant morbidity. Other predictors were breastfeeding complications and maternal knowledge on duration of exclusive breastfeeding.

These findings support the hypothesis that maternal socio-demographic characteristics, socio-economic and contextual factors are not significantly associated with exclusive breastfeeding; whereas the hypotheses that maternal health characteristics, maternal knowledge and attitudes and beliefs are not significantly associated were rejected. The findings of this study also reject the hypothesis that infant morbidity is not significantly associated with exclusive breastfeeding.

5.2 Conclusions

The exclusive breastfeeding rate in Uyo Local Government Area falls way below the level recommended by WHO. The highest rates of exclusive breastfeeding are observed up to 3 months then they decline to very low rates at 5 months. For the majority of the infants, exclusive breastfeeding stops at around 3 months.

From the findings of this study, factors that influenced exclusive breast feeding in the study community included; Infant age; Infant health; maternal morbidity; maternal experience of breastfeeding complications; maternal correct knowledge on duration of exclusive breastfeeding; maternal knowledge that breastfeeding delays pregnancy; maternal knowledge that semi-solid and solid foods should be introduced at six months and attitudes and beliefs regarding exclusive breastfeeding practices.

The strongest predictor of exclusive breastfeeding in the study community was infant morbidity. Those children who were ill were less likely to receive exclusive breastfeeding. Maternal experience of breastfeeding complications was also a predictor of exclusive breastfeeding in the study community. Mothers who experienced breastfeeding complications were less likely to exclusively breastfeed their infants. Maternal correct knowledge on duration of exclusive breastfeeding was also a predictor of exclusive breastfeeding in the study community. Mothers who had correct knowledge on duration of exclusive breastfeeding were more likely to breastfeed their infants exclusively.

5.3 Recommendations

5.3.1 Recommendations for policy

1. Ministry of Public Health and Sanitation should review the efficiency of the implementation of BFHI in the health facilities. From this study a large percentage of mothers received breastfeeding information from the health facility.
2. Breastfeeding promotion messages for mothers offered by the Ministry of Public Health and Sanitation through the health facilities should emphasize the importance of prompt health seeking behavior as maternal and child morbidity influenced the practice of EBF; correct knowledge on breastfeeding issues particularly the health benefits of exclusive breastfeeding.

5.3.2 Recommendations for practice

1. Negative attitudes and beliefs regarding exclusive breastfeeding should be addressed especially in breastfeeding messages and during counseling on infant feeding by the nutritionists, health and community health workers. In this study expressing of breastmilk was viewed as a taboo. It was a common belief that poverty constrains exclusive breastfeeding.
2. There is need to encourage and support community based strategies for the promotion of exclusive breastfeeding so that nutritionists, health workers and community health workers can reach more mothers with the knowledge on benefits and correct duration of exclusive breastfeeding. Correct knowledge on exclusive breastfeeding among the study population positively influenced the practice of exclusive breastfeeding. Innovative strategies are required to help mothers complete 6 month exclusive breastfeeding.
3. Strategies adopted by the health workers and NGOs to promote exclusive breastfeeding should also target all grandmothers, fathers and traditional birth attendants as they play a key role in influencing mothers to either exclusively breastfeed or not.

5.3.3 Recommendations for research

As a follow up of this study, the following suggestions for further research are made

1. A study on factors influencing continued exclusive breastfeeding up to 6 months in the study community. This will help in identifying ways of curbing the decline of exclusive breastfeeding especially from three months to six months.
2. Additional research is required to establish ways of improving breastfeeding counseling at the health facility level in order to make it more effective and also identify ways to sustain optimal infant feeding practices in the community.
3. Similar studies should be done in other contexts to establish factors influencing exclusive breastfeeding in order to target context specific interventions.

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