ABSTRACT
Breast-milk substitutes are infant formulas used to feed infant when breast milk is not available. This study assessed the factors that influenced the use of breast milk substitutes among the lactating mothers in Urban area of Enugu state. This study is a cross sectional survey. A well-structured and validated questionnaire was used to collect information on the socio-demographic characteristics, socio-economic, awareness and utilization of breast milk substitutes by the lactating mothers and their husband. Statistical Package Software Service (SPSS) version, 23 was used to analyze the data collected. Data were analyzed using frequency, percentage, mean and standard deviation. The result revealed that majority of the lactating mothers were given maternity leave for their delivery and more than quarter (29.3%) of the respondents were given 1month maternity leave. More than half (64.0%) of the lactating mothers had tertiary education and less than half (42.0%) earned between ₦18,500-₦49,000 monthly. Seventy three percent (73%) of the husband to the lactating mothers had tertiary education and quarter (25.7%) of them earned between ₦18,500-₦49,000 monthly, respectively. Majority (92.0%) of the lactating mother were aware of breast milk substitutes and 22.0% heard it from their husband and family members. Some (33.3%) of the lactating mothers made a personal decision on the use of breast milk substitutes, and few (1.7%) of the lactating mothers introduced breast milk substitutes to their baby after 6 months. More than half (66.3%) of the mothers were advised by doctors, nurses/midwives to feed their baby with infant formula. Few (8.0%) of the lactating mothers had good attitude towards feeding their baby with breast milk alone for the first six months after birth. Less than half (41.3%) of the infants assessed in this study were thin and skinny and 15.7% of the children had diarrhea since birth. However, the result of this study showed that majority of the mothers preferred feeding their infants with breast milk substitutes which affect the nutritional status of their respective children.
TABLE OF CONTENTS
TITLE PAGE i
CERTIFICATION ii
DEDICATION iii
ACKNOWLEDGEMENT iv
TABLE OF CONTENTS v
LIST OF TABLES ix
ABSTRACT x
CHAPTER ONE
INTRODUCTION 1
1.1 Statement of the problem 4
1.2 General objective 7
1.2.1 Specific objectives 7
1.3 Significance of the study 7
CHAPTER 2
LITERATURE REVIEW
2.1 Concept of breast milk. 9
2.2 Composition of human breast milk 11
2.3 Protein in human breast milk 15
2.4 Fats in human breast milk 16
2.5 Human milk options-milk donors and milk banks 18
2.6 Breast milk substitute (infant formulas) 19
2.6.1 The Infant Formula Market 19
2.6.2. Guidelines for Manufacturing of Infant Formula 20
2.7 Classes of breast milk (infant formula) products 22
2.7.1. Cow Milk-Based Formula 22
2.7.2. Soy-Based Formulas 24
2.7.3. Hypoallergenic Formulas 25
2.7.4. Amino Acid Formulas 25
2.7.5. Non-Bovine Milk Sources 25
2.8. Benefits of breastfeeding 26
2.8.1. Benefit for mother 26
2.8.2. Benefit to infants 27
2.8.3. Benefit to the employer 28
2.8.4 Community benefits 28
2.9 Barriers to breastfeeding at work 29
2.10 Maternal nutrition 30
2.11 Factors affecting breastfeeding in Nigeria 32
CHAPTER 3
MATERIALS AND METHODS 34
3.1 Study design 34
3.2 Area of study 34
3.3 Population of study 35
3.4 Sampling and sampling techniques 35
3.4.1 Sample size 35
3.4.2 Sampling procedure 37
3.5 Preliminary activities 37
3.5.1 Preliminary visits: 37
3.5.2 Training of the research assistants 37
3.6 Data collection 38
3.6.1 Questionnaire Design 38
3.6.2 Interview 38
3.7 Data analysis 39
3.8 Statistical analysis 39
CHAPTER 4
RESULTS AND DISCUSSIONS 41
4.1 Socio-demographic characteristics of the lactating mothers 41
4.2 Socio-economic characteristics of the lactating mothers 44
4.3 Socio-economic characteristics of the husband 47
4.4 Level of awareness and exposure to breast milk substitutes 49
4.5 Utilization of breast milk substitutes 53
4.6 Attitude of the respondents towards breast milk substitutes 60
4.7 Characteristic of the index of the child currently being breastfed 63
CHAPTER 5
CONCLUSION
5.1 Conclusion 67
5.2 Recommendations 67
REFERENCES 68
Appendix I 79
Appendix II 90
Appendix III 91
LIST OF TABLES
4.1a Socio-demographic characteristics of lactating mothers 36
4.2a Socio-economic characteristics of lactating mothers 39
4.2b Socio-economic characteristics of husband 42
4.3a Level of awareness and exposure of breast milk substitutes 44
4.3b Level of awareness and exposure of breast milk substitutes 45
4.4a Utilization of breast milk substitutes 48
4.4b Utilization of breast milk substitutes 50
4.4c Utilization of breast milk substitutes 51
4.5 Attitude of respondents towards breast milk substitutes 54
4.6a Characteristic of index of the child currently being breastfed 57
4.7 Anthropometric characteristics of children 59
CHAPTER 1
INTRODUCTION
Breast-milk is the global standard for optimal infant nutrition and health, and breastfeeding promotion is a key newborn and child survival intervention (World Health Organization (WHO), 2014).However, increase in Breast-milk Substitutes (BMS) marketing led to the promotion of breast milk substitute among working class and HIV-Infected mothers, which has been the focus of many international organizations, health professionals, multilateral organizations like WHO, United Nations Children’s Fund (UNICEF), as well as government and non-governmental organizations (UNICEF, 2017).Multiple factors influence infant feeding decisions. In addition to Breast-milk Substitutes (BMS), these include hospital or delivery center policies and practices that separate mother and baby; inadequate counseling and support and maternal lack of confidence; family or community pressures to introduce other foods or liquids, due to beliefs about thirst, health requirements, or cultural traditions; infant attributes; and lack of maternity protection and work which separates mothers and young infants (WHO, 2012).Studies have shown that the complexity of factors that affect breastfeeding include the aggressive marketing of breast milk substitutes, practices at health facility levels that have the potential to undermine breastfeeding, cultural feeding practices, economics of feeding, convenience, socio economic and demographic factors, availability as well as employment concerns (Sokol 2013, Walker and Adam, 2013). Of all these, two key factors that have been identified to contribute largely to the decline in breastfeeding and the entrenchment of bottle feeding are commercial promotion of infant food products and health care practices that encourage the use of these products (Eidelman et al., 2012)
One of the most important decisions that a pregnant woman has to make is choosing an infant-feeding method (UNICEF, 2014). The benefits of breastfeeding for newborn infants are well documented (WHO, 2015). The World Health Organization (WHO) recommends that to achieve optimal growth, development and health in infants, they should be breastfed exclusively for 6 months or adopt breast milk substitute for the unhealthy mothers (WHO, 2014). Breast-milk is a unique source of nutrition that plays an important role in the growth, development, and survival of infants (GiashuddinandKabir, 2014).
Breast milk substitute means that the child receives breast milk and any food or liquid including non-human milk (WHO, 2016). Breast milk substitute is defined as when the infant receive breast milk in addition to complementary food ((Danso, 2014; WHO, 2017). The World Health Organization (WHO) defines partial breastfeeding as being given other milk or gruel in addition to breast milk (Haider et al., 2017). Breast milk substitute is any food being marketed or otherwise represented as a partial or total replacement for breast milk, whether or not suitable for that purpose. Foods may be considered breast milk substitute depending on how they are marketed or represented. These include infant formula, other milk products, therapeutic milk, and bottle-fed complementary foods marketed for children up to 2 years of age and complementary foods, juices, teas marketed for infants under 6 months (UNICEF, 2014).
There are several factors influencing the use of breast milk substitute among lactating mothers. These include mothers’ beliefs about insufficient breast milk, support from the family members (such as the husband, mother’s mother, mother-in-law, and grandmother), financial insufficiency, household workload and mothers’ disinterest (Haider et al., 2017). The baby’s father is the most influential person for any breastfeeding practice of a lactating mother. The husband’s influence is more significant than that of health professionals (Ike, 2013). Support from a baby’s father by active participation in decision making about breastfeeding has a powerful effect on the initiation and duration of breastfeeding (Kramer and Kakuma, 2012). Mothers from rich families stopped breastfeeding earlier than mothers of poorer families due to their ability to buy powdered milk and other baby formulas (GiashuddinandKabir, 2014). Among these factors, support from family members makes a high contribution to breastfeeding. Without support from family members, it may be difficult for lactating mothers to practice and maintain their breastfeeding practice (Albrecht et al., 2014).
The mother’s physical and psychological health affects their breastfeeding practice. The mothers’ physical condition, including sore and painful nipples, breast engorgement, and mastitis are common breastfeeding problems of mothers which are related to distress and discomfort and lead them to discontinue the breastfeeding within a few weeks after delivery (Cooke et al., 2006). WHO (2011) also found that mother’s physical health was most likely the reason for stopping breastfeeding. Insufficient milk supply is another very common reason for early cessation of breastfeeding (Makrides et al., 2016). It can be caused by infrequent or incomplete breast emptying, anxiety and an inadequate maternal diet (Lonnerdal, 2012). Among psychological conditions, anxiety plays an important role in the breastfeeding practices of mothers. Luoto et al. (2014) reported that maternal anxiety influenced physiological the milk ejection reflex that might be the cause of an inadequate milk flow.
Furthermore no study on the use of breast milk substitute among lactating mothers in Enugu urban, Enugu State has been carried out in both rural and urban communities despite the high rate of infant mortality observed (Adgent et al., 2012). This present study aims to investigate the use of breast milk substitute among lactating mothers in Enugu urban, Enugu State Nigeria.
1.1 STATEMENT OF THE PROBLEM
Breast milk is a rich source of antibodies which provides immunity against bacteria and viruses to a newborn. With increasing urbanization and industrialization, more women have started working compared to earlier times, which poses a challenge to child feeding practice and health (Bhutta, Das and Walker, 2013).
Working women experience hindrance in continuing breastfeeding practices thereby adopting breast milk substitute. Changes in lifestyle and other socio-cultural practices have been found to be the major factors influencing the use of breast milk substitute among lactating mothers across the nation. Studies have shown that one of the barriers to breastfeeding is urbanization, mothers’ work status, health status and conditions at the workplace. There is no documented rate of breast milk substitute in Enugu urban but it will be obvious that the rate will be high because most of mothers in the study area are civil servants who are given little or no maternity live (walker and Adam, 2013).
Enugu urban is a civil servant and commercial area with inhabitant of different socio-cultural background. Hence breast milk substitute among lactating mothers will be also function of different cultures and social groups (Adgent et al., 2012). This made breast milk substitute practices unpopular to many lactating mothers in the study area due to urbanization, life styles and misconception regarding infant feeding practices. The World Health Organization recommends that complementary foods for infants should be derived from locally available foods. However, breast milk substitute like formula milk will be the option for majority of lactating mothers in urban areas in Enugu state.
This is because majority will be in offices and into business thus can afford them and also the facilities to prepare and feed them to the baby (Arora et al., 2010). However, the use of these breast milk substitute can contribute to under nutrition on the long run because in attempt to economize each tin the mother can offer dilute milk to the infant. Generally prelacteal foods will be known to interfere with optimal breastfeeding and can lead to infant morbidity and mortality yet it will be a common practice for over 50% of lactating mothers in Enugu state to feed plain warm water, glucose water, coconut/ bitter-kola-water and other herb concoctions to their babies immediately after birth due to cultural affiliation attached to these substances (Adgent, 2012). The use of breast milk substitute before the age of 24 months is a risk factors to malnutrition, morbidity and mortality rate among children less than twenty four months of age, current researches revealed 9-12 months as breastfeeding duration in Enugu urban (Bezirtzoglou et al., 2011).
Studies have shown that inadequate Breastfeeding information and lack of support to lactating mothers by healthcare personnel tends to influence the rate of breast milk substitute (Chassard et al., 2013). Some Health care personnel will be reported to have insufficient knowledge and credibility on Breastfeeding and thus tend to mislead lactating mothers towards Breastfeeding practices. Also some cultures and traditions are barriers to the promotion and practice of Breastfeeding by its adherents in urban areas in Enugu State. Although urbanization and maternal employment among lactating mothers may contribute to ineffective breastfeeding practices and adoption of breast milk substitute among lactating mothers. Therefore, the aim of this study is to find the use of breast milk substitute among lactating mothers in Enugu urban, Enugu State Nigeria.
1.2 GENERAL OBJECTIVE
The general objective of this present study is to determine the use of breast milk substitute among lactating mothers in selected urban area in Enugu State Nigeria.
1.2.1 Specific objectives
The specific objectives of this study are:
i. to assess the socio-demographic and economic characteristics of lactating mothers in selected urban area in Enugu State.
ii. to determine the utilization of breast milk among lactating mothers.
iii. to assess the attitude of the respondents towards breast milk substitutes
iv. to evaluate the level of awareness and exposure to breast milk substitutes
1.3 SIGNIFICANCE OF THE STUDY
This study will be salutary; as it will contribute to a better understanding of how essential health interventions with proven empirical efficacy such as breast milk feeding can be promoted. It is also hoped that this study’s outcome will contribute to the growing body of scientific knowledge on infant feeding practices and how to design and situate health interventions in urban areas of the study state.
This will help to enhance the rate of timely initiation of infants to breast milk immediately after delivery. This will help to reduce infant morbidity and mortality rate due to neonatal starvation. The findings of the study will provide nutrition education to trim down the rate of prelacteal feeding practices substantially; this will curtail the rate of infection and under nutrition and enhance child survival in the communities. It will also cut down the socio cultural practices that promotes breast milk substitutes practices in the study area.
The result of this research will provide nutritional and health education for both the Government, health workers, lactating mothers and the general public on the benefits of exclusive breast-feeding of infant’ life. This will reduce the rate of early introduction of complementary feeding, and bottle feeding rate. It is foreseen that the findings of this work will be of great benefit to all mothers despite their age in raising up healthy children, future researchers who can lay their hands on the findings for further studies on issues that are related to breast milk substitute, and health agencies that are in position of developing community health in the contemporary society. The findings can inspire the Government of Enugu state to consider the extension of the maternity leave of employed breastfeeding mothers so as to be able to breastfeed their babies up to six months as recommended by Baby Friendly Hospital Initiative.
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