Abstract
The level of knowledge, attitude and supportive practices of grandmothers towards exclusive breast feeding was assessed in the study based on the fact that exclusive breastfeeding addresses all the four facets of health of the infant which are physical, mental, spiritual and social; on the vital role and strong influence of grandmothers whose knowledge, attitude and supportive practices have a great effect on the feeding pattern of the infants. The study also determined the relationship and proximity between grandmothers and daughters/daughters-in-law in Ibere (Rural) and World Bank Housing Estate (Urban) of Abia State. A total of 239 grandmothers were sampled and interviewed. A self administered questionnaire was used in data collection and sampling accessibility which allowed contact with otherwise inaccessible respondent. The result showed that 53.8% of grandmothers had good knowledge of exclusive breastfeeding, 32.2% had average knowledge of exclusive breastfeeding, and 14.0% had poor knowledge of exclusive breastfeeding. It was found that 9.6% of grandmothers had positive attitude towards exclusive breastfeeding, 56.1% had indifferent attitude, while 34.3% had negative attitude towards exclusive breastfeeding. The result also showed that none (0.0%) of the grandmothers gave high support on exclusive breastfeeding, 28.9% gave moderate support and 71.1% gave low support on exclusive breastfeeding. The result on the relationship between knowledge, attitude and supportive practices of grandmothers towards exclusive breastfeeding showed that there is a positive and strong significant relationship (0.723, P<0.001) between the knowledge and attitude of grandmothers towards exclusive breastfeeding, which implies that grandmothers who had good knowledge of exclusive breastfeeding were found to have a positive attitude towards exclusive breastfeeding. However, there is a positive but weak significant relationship (0.270**) between knowledge and supportive practices of grandmothers towards exclusive breastfeeding. In conclusion, more than half of the grandmothers (129) had good knowledge of exclusive breastfeeding but indifferent attitude and low support towards exclusive breastfeeding. The knowledge, attitude and supportive practices of exclusive breastfeeding are learnt socially within then family. Therefore it is recommended that intervention on improving the attitude and supportive practices of grandmothers towards exclusive breastfeeding and how beneficial positive attitude and supportive practices will be to the infant at the long-run should be taken out of the hospital to homes through awareness of exclusive breastfeeding in communities to include all the stake holders that may influence exclusive breastfeeding practices especially grandmothers.
TABLE OF CONTENTS
TITLE PAGE i
CERTIFICATION ii
DEDICATION iii
ACKNOWLEDGEMENTS iv
TABLE OF CONTENTS v
LIST OF TABLES ix
ABSTRACT x
CHAPTER ONE
INTRODUCTION
1.1 Background of the study 1
1.2 Statement of Problem 6
1.3 Objectives of Study 8
1.4 Significance of Study 9
CHAPTER TWO
LITERATURE REVIEW
2.1 Concept of Breastfeeding 11
2.1.1 Nutritional qualities of breast milk 13
2.1.2 Composition of breast milk 14
2.1.2.1 Carbohydrate 14
2.1.2.2 Protein 15
2.1.2.3 Fats 16
2.1.2.4 Vitamins 17
2.1.2.5 Minerals 17
2.1.2.6 Water 17
2.1.2.7 Anti-Effective Properties 18
2.1.3 Types of breast milk 19
2.1.3.1 Colostrum 19
2.1.3.2 Fore milk 19
2.1.3.3 Hind Milk 20
2.1.3.4 Transition Milk 20
2.1.3.5 Mature Milk 20
2.1.4 Types of breastfeeding practices 21
2.1.4.1 Formula Feeding 21 2.1.4.2 Share Breastfeeding 21
2.1.4.3 Complementary Feeding 22
2.1.4.4 Exclusive Breastfeeding 22
2.1.4.5 Expressing Breast milk 23
2.1.4.6 Demand or Need feeding 23
2.1.4.7 Extended Breastfeeding 24
2.1.4.8 Tandem breastfeeding 24
2.1.4.9 Mixed Feeding 25
2.1.5 Advantages of breastfeeding to infants 25
2.1.6 Advantages of breastfeeding to mothers 27
2.1.7 Disadvantages of bottle feeding 30
2.2 Concept of attitude grandmothers of exclusive breastfeeding 30
2.3 Concept of knowledge of grandmothers on exclusive breastfeeding 31
2.4 Concept of supportive practice of grandmothers towards 33
exclusive breastfeeding
CHAPTER THREE
MATERIALS AND METHOD
3.1 Study Design 35
3.2 Area of Study 35
3.3 Population Size 36
3.4 Sample and Sampling Technique 36
3.4.1 Sample Size 36
3.4.2 Sampling Procedure 38
3.5 Preliminary Activities 39
3.5.1 Preliminary Visit 39
3.5.2 Training Research Assistants 40
3.5.3 Ethical Approval 40
3.6 Data Collection 40
3.6.1 Questionnaire design 40
3.6.2 Questionnaire Administration 41
3.7 Data Analysis 41
3.8 Statistical Analysis 43
CHAPTER 4
RESULTS AND DISCUSSION
4.1 Socio Economic Characteristics of the Mother 44
4.2 Grandmother’s Relationship and Proximity with Daughter/Daughter-In-Law 49
4.3 Grandmother’s Knowledge and Perception of Index Child 52
4.4 Grandmother’s Awareness and Level of Knowledge of Exclusive Breastfeeding 53
4.4.1 Grandmother’s Awareness of Exclusive Breastfeeding 53
4.4.2 Grandmother’s Level of Knowledge of Exclusive Breastfeeding 54
4.5 Attitude of Grandmothers on Exclusive Breastfeeding 57
4.6 Support Practices of Grandmothers on Exclusive Breastfeeding 60
4.7 Relationship between Knowledge, Attitude and Support Practices of
Grandmothers towards exclusive breastfeeding in the urban area 64
CHAPTER FIVE
CONCLUSION AND RECOMMENDATION
5.1 Conclusion 67
5.2 Recommendation 68
REFERENCES 69
APPENDIX 78
List of Tables
Table 2.1 Nutrient Composition of Breast Milk Per 100ml 18
Table 4.1a Sociodemographic Characteristics of the Grandmother 45
Table 4.1b: Sociodemographic Characteristics of the Grandmother 46
Table 4.2 Grandmother’s relationship and proximity with daughter/daughter-in-law 50
Table 4.3 Grandmother’s knowledge and perception of index child 52
Table 4.4 Grandmother’s awareness of exclusive breastfeeding 54
Table 4.5 Knowledge of grandmothers on exclusive Breastfeeding 56
Table 4.6 Attitude of grandmothers on exclusive breastfeeding 58
Table 4.7 Support practices of grandmothers on exclusive breastfeeding 62
Table 4.8 Relationship between knowledge, attitude and support practices of grandmothers towards exclusive breastfeeding in the urban area 66
CHAPTER ONE
INTRODUCTION
1.1 Background of the study
Adequate diet is more critical in early infancy than any other time in life. This is as a result of the infant’s high nutritional requirements in relation to body weight and the influence of proper or faulty nutrition during the first six months of development. Moreover, the infant is more sensitive to abnormal nutritional situations and less adaptive than later in life to different forms or types of proportions and quantities of food (Ekpunobi, 2007).
Adequate knowledge on exclusive breastfeeding is a central implement that navigates the course of breastfeeding stability and distinctiveness amongst mothers. Insufficient and defective information, with absence of support throughout this practice leads to immature cessation of breastfeeding (Regina et al., 2014). In the view of this, the United Nations International Children Emergency Fund (UNICEF) in collaboration with World Health Organization (WHO) launched a campaign to promote exclusive breastfeeding at least for the first six months of life even to two years (Ngwu, 2007). There is no longer doubt today that breast-feeding is the best way of feeding and interacting with infants. Furthermore, World Health Organization recommends that after the first six months of life, that complimentary breastfeeding should be introduced with continuous breastfeeding with supplementation for up to two years and more (WHO, 2010). Estimates show that good breastfeeding practices especially exclusive breastfeeding could prevent about 11.6 % of the 6.9 million under five deaths in developing countries (WHO and UNICEF, 2010). Exclusive breastfeeding is one of the cardinal components of the Baby Friendly Hospital Initiative (BFHI) aimed at protecting, promoting and supporting breastfeeding for optimal maternal and child health, and is part of the 1990 Innocenti Declaration which states that all governments should create an environment enabling women to practice exclusive breastfeeding for the first 6 months of life and to continue breastfeeding with adequate complementary foods for up to six months (Sajch, 2009). Not only does exclusive breast feeding prevent infection, also such children tend to be more socially and emotionally adjusted as adults and are less likely to join cults and become drug addicts (Udoh, 2013).
According to the Nigerian Demographic and Health Survey (NDHS), in 2008, 17% of the children were exclusively breastfed for less than 4 months while 13% were exclusively breastfed for less than six months. Breast feeding practices including initiation and duration of breastfeeding in low-income countries are influenced by education, employment, place of delivery, family pressure and cultural values (World Health Organization, 2010; Garter et al., 2012; Otooet al., 2013). Besides normative expectations, personal experiences and networks of supportive influence on the forms and quality of breastfeeding practices. Largely, these factors exert pressure on breastfeeding mothers thereby making their experience pleasurable or painful within time and space (Cripe et al., 2011). Breastfeeding practices are culture dependent (Schmeidet al., 2012).
Exclusive breast feeding addresses all four facets of health which are physical, spiritual, mental and social. Breastfeeding rates are influenced by a myriad of factors spanning from sociocultural to economic factors. In many societies around the world, older women are seen as owners of traditional knowledge and cultural history which has strong community significance (Bezneret al., 2008). Despite this influence, the older generation has not been a specific area of study in the field of global health (Aubel and Sihalathavong 2013). Most health programs target the individual person most directly involved in the target behavior- usually new mothers (Lewyckaet al, 2013 and Wojcickiet al, 2010) without a commensurate understanding of who else influences those decisions. The experiences and views of breast feeding mothers are complemented with that of the grandmothers.
Grandmothers are important sources of support for the new mothers. Based on the grandmother’s roles, the infant feeding experience and knowledge can influence mother’s decision to initiate and continue exclusive breastfeeding (Grassley et al., 2008). The older generation, particularly the infant’s grandmothers (either the maternal or the paternal grandmother), play a central role in various aspects of pregnancy decision-making and child rearing within the family unit (Chang et. al., 2012). Also, grandmothers pass on their knowledge, beliefs and attitude towards breastfeeding. Intervention on improvement of breastfeeding practices should be taken out of the hospital environment to include all stakeholders that may influence breastfeeding practices especially the grandmothers. Futhermore, grandmothers’ infant feeding practices influence new mothers’ decisions to initiate and continue breastfeeding (Dykes et. al., 2003). Grandmothers who breastfed transmit not only their practical knowledge of how to breastfeed but also their confidence that breastfeeding is the normal way to feed an infant (Dykes et. al., 2003). Some nursing mothers deviate from exclusive breast feeding because of the mother or mother in-law’s reason that whether an infant was exclusively breastfed or not, the infant who has been destined to be intelligent will not deviate from that (Eschiti, 2010). If a mother or mother in-law has not breastfed exclusively, she may offer advice that reflects experience with formula feeding and thus undermine her daughter’s confidence and ability to successfully establish breastfeeding (Grassley, 2008). Benjamin et al. (2001) reported grandmothers as the main group that affect breastfeeding period and support new mothers the most. Similarly, a Nepalese study among mother-in-laws noted that they “see themselves as key providers of, and decision-makers in, perinatal care practices” (Masvie, 2006). A female respondent in one of the studies on exclusive breastfeeding stated that she would only go to the clinic if her baby was sick with “my mother-in-law’s permission” (Gupta et al., 2015). Within certain contexts, evidence indicates that this influence can be particularly deleterious to exclusive breastfeeding rates. A 2012 study from Nigeria, found that paternal grandmothers pressured 25% of the mothers enrolled in the study to not exclusively breastfeed (Agunbiadeet al., 2012).
In many societies around the world, older women are seen as owners of traditional knowledge and cultural history which has strong community significance (Bezneret al., 2008). Most health programs target the individual person most directly involved in the target behavior usually new mothers (Lewyckaet al., 2013) without a commensurate understanding of who else influences those decisions. While the benefits of breastfeeding are well documented, many women continue to choose to formula feed rather than breastfeed or stop breastfeeding prior to the recommended 6-month breastfeeding (Thrower and Peoples, 2015). Women commonly have little or no information about breastfeeding before falling pregnant. Many have had little contact with women who successfully breastfeed and do not know what to expect. Knowledge and attitudes (psychosocial factors) are important factors that influence breastfeeding prevalence in general (Chambers et al., 2007). Lack of knowledge, negative attitudes and beliefs about breastfeeding by others (partners, family members, support people and the general public) can be unsupportive. The study therefore investigates the influence of grandmothers’ knowledge, attitude and supportive practices towards exclusive breastfeeding.
1.2 STATEMENT OF PROBLEM
Exclusive breastfeeding, which is essential for boosting the infant’s immunity, helps in the proper transition from one developmental milestone to another, helps in brain development, increase the infant’s intelligent quotient and supply both micro and macro nutrients necessary for proper growth of the infant has either been encouraged or discouraged by the mother in-laws for one fallacious reason or the other (Ada et al., 2012). Despite the knowledge which has been made available concerning breastfeeding practices in Nigeria, there are greater population of mothers who do not practice exclusive breastfeeding owing to the fact that their mother in-laws do not support it (Spencer and Ekpunobi, 2016), but estimates show that exclusive breastfeeding (EBF) has the potential to prevent 11.6 % of all under-five deaths in developing countries. Prevalence of exclusive breastfeeding is low globally (35 %), and in sub-Saharan Africa ranges between 22 and 33 % (Aubrey Maongaet al., 2015).
Exclusive breastfeeding rates (EBFR) reported in national surveys (UNICEF, 2006) and from different centers (Jones et al., 2008 and WHO, 2010) have been rather low (0 - 53.9%) and has proven that despite the promotion of baby friendly hospital initiative (BFHI) programs in these health institutions, more than 50% of Nigerian infants are fed complementary foods too early, which are often of very poor nutritional value (Federal Ministry of Health, National policy on infant and young child feeding in Nigeria Abuja, Nutrition division, Federal Ministry of Health, 2012). This has contributed to the current prevalence of exclusive breastfeeding in Nigeria being 17% (WHO, 2017). This prevalence is due to some factors that affect the practice of exclusive breastfeeding. These factors could be social, physical, biological and psychological, and may impact positively or otherwise on the ability and willingness of women to practice exclusive breastfeeding. Some researchers have proposed that lack of suitable facilities outside of the home, inconvenience, conflicts at work, family pressure and ignorance adversely affect the willingness of women to practice exclusive breastfeeding (Jones et al., 2018 and Gabriele et al., 2018) and also the need to return to work or school has been implicated as a factor interfering with exclusive breastfeeding. (Jones et al., 2018 and Anyamele, 2018).
The adequacy of exclusive breastfeeding has been established even globally. It is recognized and accepted, yet, it is not extensively practiced, thereby constituting a problem for the entire nation. Only very modest increase has been achieved in the race of exclusive breastfeeding for five months. This is because, in most countries, the practice of exclusive breastfeeding is being discontinued after few weeks of attempts to increase the number of people who exclusively breastfeed and has therefore caused very little success in increasing the practice of exclusive breastfeeding (Ngwu). This study is aimed at examining attitude, knowledge and supportive practices of grandmothers towards exclusive breastfeeding in selected locations in Abia state, owing to the fact that most grandmothers do not know the importance of exclusive breastfeeding, have been misled by their fallacious and naïve beliefs, which has been an evidence that no significant research has been carried out on exclusive breastfeeding practices leading to infant mortality rate in the (Precious et al., 2015).
1.3 OBJECTIVES OF STUDY
GENERAL OBJECTIVE:
The objective of this study was to assess the attitude, knowledge and supportive practices of grandmothers towards exclusive breastfeeding, in selected urban and rural locations in Abia State.
SPECIFIC OBJECTIVE:
The specific objectives of this study is to:
1) Assess the knowledge of grandmothers on exclusive breastfeeding
2) Assess the attitude of grandmothers towards exclusive breastfeeding
3) Assess the supportive practices of grandmothers towards exclusive breastfeeding.
4) Determine the relationship between the knowledge, attitude and supportive practices of grandmothers towards exclusive breastfeeding.
1.4 SIGNIFICANCE OF STUDY
The findings of this study will rebound to the benefit of exclusive breastfeeding concerning the fact that it plays vital roles in boosting infants' immunity, helping the infants to transform from one developmental milestone to another, brain development, tremendously increasing the infants' intelligent quotient and supplying both macro and micro nutrients necessary for proper growth of the infants.
The greater demands for a healthy, intelligent and patriotic younger generation justifies the need for grandmothers who have good knowledge, positive attitude and strong supportive practices towards exclusive breastfeeding, owing to the fact that grandmothers are one of the crucial decision makers on how the infant will be fed for the first six months of live.
This study therefore, will help enlighten grandmothers who their knowledge towards exclusive breastfeeding is poor, inculcate positive attitudes to those who are over taken by negative ones and build up good supportive practices among grandmothers by teaching the grandmothers the real fact of exclusive breastfeeding and eliminating the fallacies that stir up negative attitude and low to no support of exclusive breastfeeding through a well organized once-in-a-year seminar in communities which will include at least one grandmother either maternal or paternal from each household where questions will be asked concerning their attitude and support towards exclusive breastfeeding. Thus, locations where exclusive breastfeeding is made a norm as a result of this study, will be able to raise children with less risk of communicable and none communicable diseases, who will be useful academically and also industrious. This study will also help the grandmothers to properly guide their daughter/daughter in-laws into exclusively breastfeeding the infant through the knowledge acquired from the community seminar. For the researcher, the study will help uncover the numerous reasons why some grandmothers do not support exclusive breastfeeding which other researchers were not able to explore. Thus, intervention on how to promote exclusive breastfeeding will be established to ensure a healthy society.
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