INTRODUCTION
Breast
milk is the ideal food for children 0 -24 months.1 It provides all the nutrition required for the healthy growth
and development of the child. It is also a cost-effective strategy for the
prevention and control of diarrheal diseases in childhood. When adopted it can
reduce infant mortality and burden of disease attributable to childhood
infection and malnutrition.2 The concept of exclusive breastfeeding
followed the ‘Baby Friendly Hospital Initiative introduced at the WHO/UNICEF
Conference on breastfeeding 1991.3 By this concept, children are
with the exception of vitamins, medicines and mineral supplements, to be fed
exclusively on breast milk during the first six months of their life ie without water, tea or herbal preparation, and then
subsequently for two years along with complementary foods required to meet
their nutritional needs.4,5 Researches have shown that breast
feeding has benefits to the nursing mother in terms of contraception, social
bonding and financial gain, and to the child in terms of healthy physical,
social and emotional development as well as improving survival in infancy and
early months of life.5-7 The practice of exclusive breast feeding
varies with different populations, religion and locality. Although the UNICEF
global target is for every newborn infant to have exclusive breastfeeding, a
90% coverage is commonly accepted worldwide.1,5,8-10 The prevalence
of exclusive breastfeeding among children less than 6 month is still low and
not widespread in developing countries even though there is a gradually
improvement.8 A trend analysis showed an increase in the prevalence
of exclusive breastfeeding globally from 33% to 39% over a 15-year period from
1995 -2010.8 Other studies have also reported low prevalence of
exclusive breastfeeding among women in informal employment in Uganda (42.8%), Burao District of Somali (20.5%), and Mauritius (17.9%).5,9,11
In the 2018 NDHS, 29% of children had exclusive breastfeeding in the first 6
months of life.12 Similar studies in Nigeria reported prevalence of
exclusive breastfeeding of 28.5% among bankers in Mainland Local Government of
Lagos State and 17.1% among rural women in Sokoto
State.1,10 The low level of exclusive breastfeeding in developing
countries like Nigeria has been attributed to barriers and challenges
associated with breastfeeding. These includes caesarian delivery, inflammatory
conditions of the breast, lactation failures, meeting career goals, lack of
family and social support, poor knowledge of good breast-feeding practices,
etc.1,2.5 A study reported that 32.5% of nursing mothers in
Mauritius gave return to work as reason for discontinuing exclusive
breastfeeding.5 Efforts to reduce these barriers have been
introduced to improve breastfeeding practices among women and to encourage them
to exclusively breast feed their newborns during the first six months of life
before commencing complementary feeding. For instance, the advocacy for
increasing maternity leave for nursing mother from three months to six months,
the introduction of paternity leave and the establishment of creches at workplaces, the global Baby Friendly Hospital
Initiative, and the International Code for Marketing of Breastmilk
Substitute. 8,13,14
Working class nursing mothers practice exclusive
breastfeeding during their allowed three months maternity leave but resort to
formula feeding in their absence on their return to work. In Nigeria as well as
in other developing countries, nursing mothers in academia like in other
professions such as banking, are also faced with heavy academic workload and
demanding schedules which may disrupt the practice of exclusive breastfeeding.10
Data on the practice of exclusive breastfeeding among women in academia in
Rivers State is scarce, therefore this study sought to assess exclusive
breastfeeding practices of women employed in tertiary institutions in Rivers
State, Nigeria.
MATERIAL AND METHOD
Study area
This
study was carried out in Rivers State, one of the oil-mineral producing States
in South-South Nigeria. It has Port
Harcourt as its capital and a projected population of 6.2 million people.15
There are six tertiary institutions in the State
comprising of three degree awarding Universities, two Polytechnics and one
College of Education awarding National Diploma certificates. Rivers State also
has two public tertiary care health facilities, 18 secondary level health
facilities, 384 public and 211 private primary level health facilities that
provide healthcare services including prenatal, natal, and postnatal services
to women of reproductive age.16 Majority of these health facilities
are baby friendly health facilities that encourage exclusive breastfeeding to
nursing mothers.
Study design and sampling
This is a descriptive
cross-sectional study carried out among women of reproductive age employed in
the tertiary institutions in Rivers State as an academic staff who have or has had at least one living child. Excluded in
this study were women of reproductive age managed for HIV/AIDS, women whose
last babies were adopted or are nulliparous. Sample size determination was done
using the Cochrane formula for single population: n = Z2pq/d2, where n is minimum sample size
required,; Z is the standard normal
deviate corresponding to 95% confidence level (1.96), p is an assumed
prevalence of exclusive breastfeeding (28.5%) [10] (0.285); q = 1-p = 0.715; d is
the degree of precision (5%) = 0.05. this
was adjusted to accommodate a non-response rate of 10%. The minimum sample size of 344 was
determined. This was however increased to 360.
Data collection and analysis
Ten Departments
in each institution were selected by simple random sampling using a list of
Departments as sampling frame and a proportionate sample taken from each
selected Department. A total of sixty participants were recruited from each of
the six tertiary institutions in Rivers State giving a total participant of
360. An interviewer administered pretested survey questionnaire was used to
collect information on respondent’s socio-demography, obstetrics history,
knowledge of exclusive breastfeeding, breastfeeding practices, and reasons for
not practicing exclusive breastfeeding.
Data
was cleaned and entered into IBM SPSS Statistics version 22 and analyzed.
Results were presented in frequency tables. Summary statistics was done using
percentages for categorical variables and means for continuous variables.
Primary
outcome variables
1.
Knowledge of exclusive breastfeeding: this was determined a priori using the
proportion of respondents who knew that exclusive breastfeeding means ‘giving
only breastmilk to a newborn in the first six months
of life.’
2.
Practice of exclusive breast feeding: was determined as the proportion of
respondents who fed their last babies with only breast milk in the first six
months of life.
Ethical
approval
Ethical
approval was obtained from the Ethics and review committee of the Rivers State
University Teaching Hospital Port Harcourt, Nigeria. Participants were assured
of their safety in the study and the confidentiality of their information and
subsequently written informed consent were obtained from them before data
collection.
RESULTS
A
total of 360 women of reproductive age participated in the study. Less than one
fifth (n = 62; 17.2%) of the participants were of the rank of lecturer 1 and
above with mean age of 41.83±8.4 years. Almost all the participants (n = 324;
90%) were married, majority (n = 118; 32.7%) have three living children and
attend Pentecostal churches (n = 211; 58.6%). Two third (n = 238; 65.6%) have
Masters’ degree and above. (Table 1)
Majority of the respondents (n = 151; 42.0%) had their
last children within 5 years of the study. Nearly all of them (n = 354; 98.3%)
attended antenatal care services with 306 (85.0%) attending four or more times
and 339 (95.8%) counselled on breastfeeding and child
nutrition. Nearly all the respondents (n = 328; 91.1%) delivered in health
facility which is baby friendly (n = 325; 90.3%). Most of them had spontaneous
vaginal delivery (n = 205; 56.9%) of their baby with mean weight of 3.43±0.59
kg (Table 2).
Table 3 shows that respondents who knew that exclusive
breastfeeding means ‘giving breast milk alone to newborns in the first six
months of life were 332 (92.2%) and that ‘medicine can be given to babies
before six months’ were 250 (69.4%) while 294 (81.7%) knew that ‘Breast milk
has all the baby require for adequate nourishment in the first six months of
life’.
Almost all (n
= 351; 97.5%) of the respondents breastfed their last babies for a mean
duration of 10.5±6.1 months. Among children breastfed, 145 (41.3%) commenced
breastfeeding within 1 hours of birth, 243 (69.2%) received colostrum, 217
(61.8%) were fed four or more times daily and slightly more than half (n = 180;
51.3%) were fed over 10 - 20 mins at each feed. There
were creche facilities at work for two third (n = 247;
68.6%) of the respondents and 151 (43.0%) expressed breastmilk
for their babies while at work. Only 101 (28.8%) of the respondents had
problems with breastfeeding, commonly delayed milk flow (n = 39; 38.6%),
cracked nipple and insufficiency of milk (n = 28; 27.7%) while 65 (64.3%) knew
how to manage their breastfeeding problem (Table 4).
Among respondents who breastfed 216 (61.5%) did
exclusive breastfeeding, 16 (7.4%) breastfed beyond 12 months. Social support
for exclusive breastfeeding were received by 117 (54.2%) commonly from
mother/siblings (n = 79; 67.5%), husbands (n = 52; 44.4%) and house helps (n =
40; 34.2%). Among those who did not exclusively breastfeed their babies, the
most common reason was ‘return to work’ (n = 24; 17.8%) however, lack of social
support was not a reason for not practicing exclusive breastfeeding (Table 5).
DISCUSSION
The
practice of breastfeeding is a cultural issue and occurs worldwide.17,18 The practice of feeding newborns in their first
six months of life with only breastmilk with
exception of medicine have however, been studied in different populations
worldwide and reported to be low.4,10 This study was done among
highly educated women working as academics in tertiary institutions in Rivers
State Nigeria. About
four-fifth (89.7%) of these women were junior cadre academics below the rank of
Senior Lecturer. The study looked at their knowledge and practice of
exclusive breastfeeding. It found that the knowledge of exclusive breastfeeding
among female lecturers was very high. For instance, more
than four-fifth of the participants knew that exclusive breastfeeding means
‘Giving breast milk alone to newborns in the first six months of life’ and
that ‘Breast milk has all the baby requires for adequate nourishment in the
first six months of life’.
The very high knowledge of exclusive breast feeding in
this study may be because of the high level of education of the women or their multiparity. Less than 10% of these women possess
educational qualifications below Bachelors’ degree and approximately one-third
(33%) have three children with majority of them (42%) having their last
delivery in the last 5 years which may suggest their previous experiences with
breastfeeding. Ihudiebube-Splendor et al (2019)
reported poor knowledge of exclusive breast feeding among primiparous
women in Enugu, Eastern Nigeria.4 Furthermore, majority of these
women delivered in hospital with nearly all of them attending antenatal care
services more than four times in a baby friendly hospital and received
counseling on exclusive breast feeding and child nutrition during these visits.
Although this study did not explore sources of knowledge of breastfeeding,
their knowledge may have been acquired from basic health education and
promotion messages following contact with healthcare providers. Therefore, this
brings to fore the need for healthcare providers to maximize opportunities for
delivery of health messages that can address myths and misconceptions that
discourage unhealthy breastfeeding behaviours.11 The knowledge of
exclusive breastfeeding has also been reported in other studies to be high. For
instance, Osibogun et al (2018) reported that 77.5%
of bankers in Lagos mainland knew that breast milk should be given alone in the
first six months and Amosu et al (2011) found that
96.5% of women in formal employment in Southwest Nigeria, had knowledge of the
benefits of breastfeeding.10,19
Almost all the women (97.5%) breastfed
their babies for a mean duration of 10. 5±6.1 months with only one in ten of them
giving pre-lacteal feed (gripe water or formula milk) as first food. Akadiri and Adetola (2020) also
reported that 93.4% of women in Southwest Nigeria breastfed their babies.17
Approximately two fifth (41%) of the mothers in this study commenced
breastfeeding within the first one hour of birth as recommended by WHO, about
two-third (59%) gave their children colostrum. Similar findings on time of
initiation of breastfeeding have also been documented in studies elsewhere. For
instance, Afam-Anene et al (2020) documented that one
third (33%) of mothers working in a tertiary institution in Imo State commenced
breastfeeding within one hour of delivery, 38.8% among women in Southwest
Nigeria and 54.2% of the nursing mothers in Sudan.2,6,17 The
initiation of breastfeeding within one hour after birth was reportedly higher
(70%) among physician-mothers in Ife Osun State.20
This finding may be because these women as physicians are role models who knew
the benefits of early initiation of breastfeeding. The early initiation of
breastfeeding has been reported to enhance bonding between the newborn and
mother, and that it reduces breastfeeding failures.1,6
This study found that most of the mothers (61.8%)
breastfed their babies more than four times daily with each breastfeeding
lasting 10 -20 minutes in about half (51.3%) of them. Among rural women in Sokoto State, Nigeria, 86.0% of the mothers breastfed their
children on demand and 3.7% feeding up to 8 times daily.1
Although WHO recommend that 90% of children be fed
breast milk exclusively in the first six months and continued for two years in
addition of complementary feeding after six months, only 61.5% of mothers in
this study who breastfed their babies practiced exclusive breastfeeding. Among
these 51.4% fed for only six months while 7.4% for 12 months and above. The
prevalence of exclusive breastfeeding in our study is comparable to those
reported among women in Southwest Nigeria (58.8%) and among caregiver attending paediatric and immunization clinics in Kano State Nigeria
(68.5%).17,21 Similar study among working women in tertiary
institutions in Imo State Nigeria reported a lower prevalence of exclusive
breastfeeding of 33.4% which may be due the inclusion in their study of
non-academic staff whose work schedules are not as flexible to allow for
exclusive breastfeeding compared to those in academia.2 It has been
reported that breast feeding could create conflicts at work when the work
environment is inconvenient and there are no workplace facilities for
breastfeeding.2 Furthermore, a lower prevalence of exclusive
breastfeeding was also reported in related studies in Nigeria among rural women
in Sokoto (17.1%),
bankers in Lagos mainland (28.7%), physician-mothers in Ife Osun State (28%) 1,10,20 and elsewhere among
Sudanese women (29.4%), women in Northwestern Romania (46.7%) and among women
in informal sector in Kampala (42.8%).6,11,22 Cultural differences
in these populations may account for this variation in the reported prevalence
rate of exclusive breastfeeding.
Only 7.4% of women in this study continued exclusive
breastfeeding beyond 12 months. This is very low compared to 70% reported among
women in Southwest Nigeria.17 The low
continuation rate in this study may be due to the differences in the work
schedules of mothers in this study who are academics with inflexible work
schedules compared to the larger population. The common breastfeeding problem
experienced by women in this study were delayed milk flow (38.6%), cracked
nipples (27.7%), perceived insufficiency of milk (27.7%), breast pain (24.8%)
and breast engorgement (10.9%) which have also been reported in other studies.5,17,18
These problems are likely to discourage the practice of exclusive breastfeeding
or disrupt its continuation beyond six months.6
More than half of our population (64.3%) knew how to
manage the problems associated with breastfeeding. About half of the mothers
had social support for exclusively breastfeed mainly from their mothers and
siblings (36.6%), husbands (24.1%) and house help (18.5%). These may also be
the reason for the moderate exclusive breastfeeding behaviour
of women in this study. Social support particularly from the
husbands play key roles for successful exclusive breastfeeding. Western
values and behaviour especially among the educated
women have projected the breast more as a sex object because of its
attractiveness than as an appendage required to provide nourishment for
infants.19 In their study Amosu et al
(2011) found 66.0% of husbands supporting exclusive breastfeeding for 4-6
months and only 19.0% for 2 years whereas among bankers in Lagos mainland, 44%
of husbands supported exclusive breastfeeding.10,19
Among those who did not practice exclusive
breastfeeding, return to work was the most common reason (17.8%) followed by
poor knowledge (9.6%) on how to practice exclusive breastfeeding at work and
the perception that breast milk is inadequate to meet the nutritional
requirements of the babies (8.9%). Other studies have similarly reported return
to work, pregnancy for the next child, short duration of maternity leave,
inconvenient work environments, fear of excessive weight gain, perception of
breast milk as nutritionally inadequate, etc.1,2,5,6,10 These
reasons can be obviated by increasing the education of pregnant women on
breastfeeding skills and techniques during ANC visits and medical consultations
so that they can ensure their babies have unrestrained access to breast milk
which is safe and of high nutritive value.23 Furthermore, this study
found that two-third of the women had creche facility
at work, 19.4% use them while 43.0% express milk for their babies at home when
at work. The implication of this is that institutions employing women of
reproductive age should provide facilities and environments that can enable
nursing mothers breastfeed their babies.
In this study data collection relied on memory recall,
which is subject to bias however, information obtained were limited to the last
birth experience of the respondents. Again, the study population
are only women in academia in Rivers State therefore generalization on
the entire population of women outside this population may be misleading.
The predictors of exclusive breastfeeding among this
population were beyond this study, therefore further research to explore the
predictors of practice of exclusive breast feeding among these
population is recommended.
CONCLUSION
The knowledge of exclusive
breastfeeding is high among mothers in academics in Rivers State Nigeria. There
is a gap between the practice of breastfeeding and exclusive breastfeeding
among mothers in academia. Although almost all the mothers breastfed their
babies for variable length of time, the practice of exclusive breastfeeding and
early initiation of breastfeeding within one hour of birth is moderately low
and below the recommendation of WHO.
Competing interest: Nil conflict of interest
Financial support: This research was entirely funded by the authors.
Authors’ contribution
BOO: conceptualization, design of the study, data analysis, final draft
NN: data collection, interpretation of data, initial draft,
review of final draft
YI: Data collection, review of initial and final draft,
literature search
NE: Data collection, literature search,
review of final draft.
Acknowledgement: The authors
acknowledge the management of the tertiary institutions who approved the
conduct of the study in their institutions and the research assistants: Mrs Mercy Bekwe and Miss Clara Joram, who facilitated the data collection and entry.
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