ABSTRACT
This cross-sectional study aimed to assess breastfeeding practices of mothers in urban (Owerri Municipal LGA) and rural (Obowo LGA) areas of Imo State. A total of 250 lactating mothers, with infants 0-12 months, attending postnatal clinics at selected health facilities were purposively selected and used for this study. A structured questionnaire was used to elicit information on socioeconomic characteristics, knowledge, attitude and practice of breastfeeding by mothers in both areas. Data obtained were analyzed using descriptives and chi-square statistics with SPSS software version 20.0. Majority of the lactating mothers were in the age range of 26-35 years. In both areas studied, most of the mothers (67.6%) had fair knowledge of breastfeeding, and 60% had good attitude towards breastfeeding. Significant differences were observed in breastfeeding practices between urban and rural mothers in terms of prelacteal feeding (x2=9.993; p=0.019), exclusive breastfeeding (x2=10.183; p=0.006), complementary feeding (x2=8.522; p=0.014), and method of feeding the baby in the absence of the mother (x2=18.525; p=0.000). Socio-demographic factors that mostly affected breastfeeding practices were total family income, number of children in the household, maternal educational status and maternal monthly income (p<0.05). Efforts should therefore be made by family and society to protect, promote and support appropriate breastfeeding practices among urban and rural mothers.
TABLES OF CONTENTS
TITLE PAGE i
CERTIFICATION ii
DEDICATION iii
ACKNOWELEDGEMENTS iv
TABLE OF CONTENTS v
LIST OF TABLES ix
LIST OF FIGURES x
ABSTRACT xi
CHAPTER 1
INTRODUCTION 1
1.1 Statement
of problem 4
1.2 Objectives
of the study 7
1.3 Significance
of the study 8
CHAPTER 2
LITERATURE REVIEW 9
2.1 Breastfeeding 9
2.2 Breastfeeding
terminologies 10
2.2.1 Early
breastfeeding 10
2.2.2 On-demand
breastfeeding 11
2.2.3 Exclusive
breastfeeding 11
2.2.4 Expressed
breast milk 12
2.2.5 Predominant
breastfeeding 13
2.2.6 Mixed
feeding 13
2.2.7 Induced
lactation 13
2.2.8 Tandem
breastfeeding 13
2.2.9 Extended
breastfeeding 14
2.2.10 Shared
breastfeeding 14
2.2.11 Weaning 15
2.2.12 Re-lactation 15
2.3 Breast
milk 15
2.4 Lactogenesis 17
2.4.1 First
stage of lactogenesis 17
2.4.2 Second
stage of lactogenesis 17
2.5 Lactation 18
2.5.1 Prolactin
(PRL) 19
2.5.2 Oxytocin 19
2.5.3 Let-down
reflex 22
2.6 Properties
and components of breast milk 23
2.6.1 Colostrum 24
2.6.2 Mature
milk 25
2.6.2.1 Protein in human milk 25
2.6.2.2 Lipids in human milk 25
2.6.2.3 Carbohydrate in breast milk 26
2.6.2.4 Vitamin content of breast milk 26
2.6.2.5 Mineral content of breast milk 27
2.7 Nutritional
requirements of breastfeeding women 29
2.7.1 Energy 29
2.7.2 Protein 29
2.7.3 Vitamins
and Minerals 30
2.7.4 Fluids 30
2.7.5 Food
choices 30
2.7.6 Supplementation 31
2.8 Benefits
of breastfeeding 31
2.8.1 Benefits
for the infant 32
2.8.1.1 Optimal and balanced nutrition 32
2.8.1.2 Greater immune health 32
2.8.1.3 Improved cognitive performance 32
2.8.1.4 Reduced risk of chronic conditions 33
2.8.1.5 Reduced risk of urinary tracts,
diarrhoeal and middle ear infections 33
2.8.1.6 Reduced risk of allergic diseases
(atopy) 34
2.8.1.7 Reduced risk of necrotizing enterocolitis
(NEC) 34
2.8.2 Benefits
of breastfeeding for the mother 35
2.8.2.1 Psychological benefits 35
2.8.2.1.1
Maternal postpartum depression 35
2.8.2.1.2
Emotional bonding and close interaction with the infant 35
2.8.2.2 Physiological
benefits for a breastfeeding mother 36
2.8.2.2.1
Reduced risk of breast and ovarian cancer 36
2.8.2.2.2
Reduced risk of type 2 diabetes 36
2.8.2.2.3 Natural postpartum amenorrhoea 36
2.8.2.2.4
Improved postpartum weight loss 37
2.8.2.3
Economic benefits of breastfeeding 37
2.8.2.3.1
Savings to the overall national economy 37
2.8.2.3.2
Savings on formula costs 37
2.8.2.3.3
Improved parent’s work attendance 38
2.8.2.3.4
Lowered infant morbidity 38
2.8.2.4
Environmental benefits of breastfeeding 38
2.9 Breastfeeding
knowledge of mothers 38
2.10 Attitude
of mothers towards breastfeeding 39
2.11 Breastfeeding practices of mothers 40
2.11.1 Early initiation of breastfeeding 40
2.11.2 Giving
of colostrum 41
2.11.3 Prelacteal
feeding 42
2.11.4 Exclusive
breastfeeding 42
2.11.5 Duration
of breastfeeding 42
2.12 Breastfeeding
Positions 43
2.12.1 Cradle
hold 44
2.12.2 Cross-over
hold 44
2.12.3 Football
hold 44
2.12.4 Reclining
position 45
2.12.5 Supine
position 45
2.13 Factors
affecting breastfeeding 45
2.13.1 Maternal
age 45
2.13.2 Socioeconomic
status 46
2.13.3 Maternal
attitudes, confidence and intentions 47
2.13.4 Maternal
employment status 47
2.13.5 Sources
of support 48
2.13.6 Hospital
policies 49
2.13.7 Health
care professionals and breastfeeding 50
2.13.8 Medical
conditions precluding breastfeeding 51
2.14 Strategies
for promotion of breastfeeding 51
2.14.1 Strengthening
of health systems and services 52
2.14.2 Strengthening
of national policies and legislation 54
2.14.2.1 Maternity protection 54
2.14.2.2 International code of marketing of
breast milk substitutes 55
2.14.2.3 Strengthening family and community
practices 55
2.15 Breastfeeding
recommendations for HIV-positive mothers 56
CHAPTER 3
MATERIALS AND METHODS 59
3.1 Study
design 59
3.2 Area
of study 59
3.3 Population
of the study 60
3.4 Sampling
and sampling techniques 60
3.4.1 Sample
size 60
3.4.2 Sampling
procedure 61
3.5 Preliminary
activities 62
3.5.1 Preliminary
visits 62
3.5.2 Training
of research assistants 63
3.6 Data
collection 63
3.6.1 Questionnaire
administration 63
3.7 Data
analysis 64
3.8 Statistical
analysis 64
CHAPTER 4
RESULTS AND
DISCUSSION 65
4.1 Socio-demographic
characteristics of the breastfeeding mothers 65
4.2 Hospital
and antenatal information of the breastfeeding mothers 68
4.3 Knowledge
of nursing mothers on breastfeeding 71
4.4 Attitude
of nursing mothers towards breastfeeding 73
4.5 Differences
in breastfeeding practices between urban and rural
Mothers 74
4.6 Factors
affecting the breastfeeding practices of mothers 87
4.6.1 Socio-demographic
factors affecting breastfeeding initiation time 87
4.6.2 Socio-demographic
factors affecting use of prelacteal feeds 90
4.6.3 Socio-demographic
factors affecting feeding of colostrum 95
4.6.4 Socio-demographic
factors affecting exclusive breastfeeding
Practice 99
4.6.5 Socio-demographic
factors affecting early complementary feeding 101
CHAPTER 5
CONCLUSION 106
5.1 Conclusion 106
5.2 Recommendations 107
REFERENCES 108
Appendix I 125
Appendix II 127
Appendix III 128
Appendix IV 135
LIST
OF TABLES
|
Table 2.1:
|
Composition and nature of human milk and
cow milk
|
28
|
|
Table 4.1:
|
Socio-demographic characteristics of the
breastfeeding mothers
|
66
|
|
Table 4.2:
|
Hospital and antenatal information for
the breastfeeding mothers
|
70
|
|
Table 4.3:
|
Knowledge of nursing mothers on
breastfeeding
|
72
|
|
Table 4.4:
|
Attitude of nursing mothers towards
breastfeeding
|
74
|
|
Table4.5a:
|
Differences in breastfeeding practices
between urban and rural mothers
|
75
|
|
Table4.5b:
|
Differences in breastfeeding practices
between urban and rural mothers
|
79
|
|
Table4.5c:
|
Differences in breastfeeding practices
between urban and rural mothers
|
82
|
|
Table4.6a:
|
Socio-demographic factors affectingbreastfeeding
initiation time
|
88
|
|
Table4.6b:
|
Socio-demographic factors affecting use
of prelacteal feeds
|
92
|
|
Table4.6c:
|
Socio-demographic factors
affectingfeeding of colostrum
|
97
|
|
Table4.6d:
Table4.6e:
|
Socio-demographic factors affecting
exclusive breastfeeding practice
Socio-demographic factors affecting
complementary feeding
|
100
103
|
LIST OF FIGURES
|
Figure2.1:
|
The let-down reflex
|
22
|
|
Figure2.2:
|
Model for breastfeeding practice based on
theory of planned behaviour
|
43
|
CHAPTER 1
INTRODUCTION
Appropriate
breastfeeding practices have been identified as an effective way of reducing
infant and child mortality caused by childhood illnesses such as diarrhoea,
measles and pneumonia (World Health Organization WHO 2016). This is so because
breastfeeding is a natural, evidence-based and cost-effective way of providing
optimal and appropriatenutrition for the healthy growth, development and
survival of infants (WHO, 2016). In fact, it is one of the defining
characteristics of being a mammal.Breastfeeding also plays an invaluable role
in the reproductive process and provides many health benefits to both mother
and infant (Kramer and Kakuma, 2004).
In 2001, the World
Health Organization (WHO) released global recommendations for infant feeding
practices (WHO, 2016). Appropriate breastfeeding practice, as recommended by
WHO, means early initiation of breastfeeding within the first hour of delivery,
no prelacteal feeding, no discarding of colostrum, breastfeeding on demand, and
giving only breast milk (i.e. Exclusive Breastfeeding (EBF)) till 6 months of
age, after which nutritionally adequate and safe complementary foods are
introduced with continued breastfeeding up to 2 years of age or beyond (WHO,
2016).
Breast milk provides
all the essential nutrients that are needed by an infant in this early period
of life, and in addition to complementary foods meets its nutritional needs in
early childhood (Oluwafolahanet al.,
2015).The composition of breast milk undergoes changes in quality to meet the nutritional
and immunological needs of a baby at different stages of child growth
(Hendrickson and McKeown, 2012).Colostrum, the yellowish, sticky breast milk or
fluid produced immediately after delivery,is compositionally distinct, with higher
concentrations of protein, vitamins A and B12 than in mature milk, and
also contains immunoglobulin, especially immunoglobulin A (IgA) which has a
protective role against viral and bacterial pathogens in the gut(Wagner et al., 2015).
In many sub-Saharan African settings, early
infant feeding practices have been influenced by a variety of less favourable
habits, both cultural and thosepropagated by health facilities (Fadnes et al., 2010). Such habits are
separation from the mother, early cord clamping, early bathing of baby and
separate cleansing rituals of the mother before initiation of breastfeeding,
and routine feeding (Fadnes et al.,
2010). These habits have been practised rather than the recommended early
skin-to-skin contact, immediate breastfeeding and feeding-on-demand (Fadnes et al., 2010; Tawiah-Agyeman et al., 2008). Furthermore, traditional
practices such as expressing and discarding of colostrum due to the belief that
it contains dirt, giving pre-lacteal feeds as part of religious ceremonies and
other rituals have also disturbed the vulnerable early feeding period
(Davies-Adetugbo, 2001; Iliyasuet al.,
2006). Generally,
families in rural areas are less educated and are more likely to be living in
poverty than theirurban counterparts (Schwartz, 2008). Many mothers in the
rural areas are unaware of the maternal and infant benefits of breastfeeding
and the consequences that accompany inappropriate infant feeding practices
(Schwartz, 2008). This is mostly due to the dearth of pre- or antenatal care
available and accessible to them (USAID, 2001).
On the maternal side,
the consequences of poor breastfeeding practices are that the mother deprives
herself of the natural contraceptive effect offered by breastfeeding and she is
at a higher risk of developing ovarian and breast cancers (WHO, 2016). On the
side of the infant, babies who are artificiallyfed or bottle-fed are
predisposed to developmental problems such as impaired sensory and cognitive
development, and are also deprived of the natural protection that breastfeeding
gives against infectious and chronic diseases (WHO, 2016).
In spite of the WHO
global recommendations for infant feeding practices, global estimates reveal
that more than 15% of mothers do not follow the recommended infant feeding
guidelines (Obermeyer and Castle, 2001). Globally, only about 36% of infants
0-6 months are exclusively breastfeed (WHO, 2016). As reported by the Nigeria
Demographic and Health Survey (NDHS) (2013), breastfeeding is very common in
Nigeria, with 98% of children ever breastfed. However, just one-third of these
children were given breast milk within one hour of birth (32%), and less than
two-thirds were given breast milk within 24 hours of birth (63%). Overall, the
median duration of any breastfeeding in Nigeria is 18.2 months, while the
median duration of exclusive breastfeeding(EBF) is only half a month (17%)(NDHS,
2003; NDHS, 2013).
There is need to
protect, promote and support appropriate breastfeeding practices for optimal
maternal, infant and young child nutrition and health in Nigeria,so as to
achieve the implementation of theWHO/UNICEF(1990)
Innocenti Declaration, which states that all governments should create an
enabling environment for women to practise exclusive breastfeeding(EBF) for the
firstsix
months of life and to continue breastfeeding with adequate complementary foods
for up to two years(Ukegbu and Anyika-Eleke, 2013).
This study was
therefore designed to assess the knowledge, attitude and practice of
breastfeeding among mothers in urban (Owerri Municipal LGA) and rural (Obowo
LGA) areas of Imo State, Nigeria.
1.1 STATEMENT OF PROBLEM
Poor infant feeding practices have been responsible,
directly or indirectly, for 60% of the 10.9 milliondeaths annually among under-five
children (Piwoz and Preble, 2000). Well over two-thirds of these deaths, which
are often associated with inappropriate breastfeeding practices, occur during
the first year of life (Piwoz andPreble, 2000). Not more than 36% of infants
worldwideare exclusively breastfed during the first months of life, with
complimentary feeding frequently beginning too early or too late, and foods are
often nutritionally inadequate and unsafe (WHO, 2016).
According
to the NDHS(2013), breastfeeding is almost universal in Nigeria, with 98% of
children ever breastfed. However, just one-third of these children were given
breast milk within one hour of birth (32%), and less than two-thirds were given
breast milk within 24 hours of birth (63%).The prevalence of early initiation
of breastfeeding (within 1 hour) varies according to specific background
characteristics, including area of residence (40% in urban areas and 29% in
rural areas) (NDHS, 2013). The data also showed that 59% of newborns were given
something other than breast milk (prelacteal feed) during the first three days
of life (NDHS, 2013). It also reported that 84% continue breastfeeding at age 1,
and 35% continue to breastfeed until age 2 (NDHS, 2013). Overall, the median
duration of any breastfeeding in Nigeria is 18.2 months, with the Northwest
having the highest duration (21.8 months) and the Southeast having the lowest
(14.1 months)(NDHS, 2013). The median duration of EBF is only half a month, with a
fluctuatingprevalence of 17% in 2003, 13% in 2008 and 17% in 2013 (NDHS, 2003;
NDHS, 2008; NDHS, 2013). Elsewhere, in sub-Saharan East Africa,the prevalence
of EBF is 13.3% in Nairobi, Kenya; while in some Southeast Asian communities it
is 36% in rural Bangladesh, and 10% in rural Haryana, India (Lakati et al., 2002; Joshi et al., 2014; Kishore et al.,
2009).
Furthermore,
the practice of giving infants colostrum differs among African countries and
likely within each country as well (Kakute et
al., 2005). A study conducted in Yobe State, Nigeria, reported that 57% of
mothers admitted giving colostrum and that the practice of discarding colostrum
and replacing it with a wide range of prelacteal feeds was observed in more
than 60% of the communities, probably due to their belief that it was of
no use to their infants (Ajibuah, 2013). In NorthwestCameroon, the women wait
for at least 2 days to breastfeed their babies, citing that colostrum is
considered to have no nutrients and is thought to have a ‘bad’ colour; they
prefer to give cow's milk instead (Kakute et
al., 2005). They also give ‘Viindi’
water which is ‘water that has been used to wash off passages of the Koran written
in charcoal on a tablet’ (Kakute et al.,
2005). Elsewhere in South Asian countries, the prevalence of early initiation
of breastfeeding within 1 hour of birthis merely 41%, with the worst global
rates in Pakistan, India, Bangladesh and Nepal as only 29%, 41%, 47% and 45%,
respectively (UNICEF, 2014).
Artificial
feeding increases the risk of diarrhoeal disease and malnutrition, which in
turn substantially increases the risk of infant mortality (WHO, 2006). This
problem can be encountered in infants on supplementary feeding. The problem
comes when infants are weaned off the breast milk too early(Ajibuah,
2013).
Consequently, the
NDHS (2013) estimates infant mortality to be 100/1,000 live births for the
1999-2003 period. It further states that the rural infant mortality rate
(121/1,000) is considerably higher than the urban rate (81/1,000), due in large
part to the difference in neonatal mortality rates (NDHS, 2013). More effort is
therefore needed to protect, promote and sustain the appropriate and extensive
practice of breastfeeding. This study seeks to find out what knowledge mothers
have as far as breastfeeding is concerned and to assess the relationship
between their knowledge on nutrition and breastfeeding practices.
1.2 OBJECTIVES OF THE
STUDY
The general objective
of the study is to assess the breastfeeding practices of mothers in urban (Owerri
Municipal LGA) and rural(Obowo LGA) areas of Imo State.
The specific objectives include to:
i.
assess the knowledge of nursing
mothers on breastfeeding.
ii. assess the attitude of nursing mothers
towards breastfeeding.
iii.
examine the differences in
breastfeeding practices between urban and rural mothers.
iv.
determine the factors influencingbreastfeeding
practices of mothers.
1.3 SIGNIFICANCE OF THE
STUDY
At the end of this study, the findings will
help to identify some of the major challenges and key factors affecting
appropriate breastfeeding practices amongst nursing mothers in both urban and
rural areas. It will help society to appreciate the benefits associated with
breastfeeding, which will propel them to encourage and support the practice.
Furthermore, it will enable governments andnon-governmental organizations
(NGOs) toknow their roles in enhancing breastfeeding practices. It will also go
a long way inenabling the government to achieve the implementation, in Imo
State particularly and the nation at large, of the WHO/UNICEF Innocenti
Declaration, by knowing how and where to channel her maternal/infant health
programmes in the urban and rural areas. Finally, this study will help policy
makers to formulate policies that will help to promote appropriate
breastfeeding practices in Nigeria.
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