ABSTRACT
The importance of breast milk over all other types of milk as the main food
source for infants cannot be over-emphasized as established by numerous health and
nutrition organizations. Early childhood is characterized by rapid growth,
development of tissues and formation of organs. Breastfeeding is the optimal method
for feeding infants. All the nutritional needs of children are provided by breast milk
in the right amounts and duration. In Nigeria however, young infants may not benefit
from this practice as a result of poor early initiation and the use of other liquids
undermining breast milk. Therefore, the practice of exclusive breastfeeding has been
recognized as a very important public health tool in preventing child morbidity and
mortality. Consequently, the WHO and UNICEF passed bills that recommended
exclusive breastfeeding for the first six months of life and subsequent introduction to
viii
complementary foods. However, efforts to promote exclusive breastfeeding have
achieved limited success and run into severe problems due to poor understanding of
the several influences on the practice. As a social institution and more importantly
the basic unit of society, the aim of this study was to seek an in-depth understanding
of family influences on exclusive breastfeeding and to determine the knowledge and
practice of exclusive breastfeeding among mothers of infants in the Wurro-Chekke
area of Yola South, Adamawa State.
Using a qualitative method with unstructured interviews as data collection
instrument; a total of one hundred and thirty mothers with children aged 7 to 24
months participated in the study. All interviews were audio taped, transcribed, and
analyzed using several analytic procedures. Four themes emerged in relation to the
forms of family influences on exclusive breastfeeding: family knowledge of
exclusive breastfeeding; collective sense of duty; family beliefs and practices and
learning to breastfeed. Given how the family participates and influence infant
feeding practices, it is suggested that public health education must aim at increasing
the awareness of family members on breastfeeding recommendations and also strive
to work with traditional and community leaders so as to modify and/or discourage
practices that involve feeding newborns with herbal remedies and concoctions.
The results show that 23.1% of the mothers understood the correct definition
and duration of EBF as recommended by the WHO. Most of the women (77%) got
this information from health workers during their visits to primary health care centres
while others (12.3%) got their information from health programs aired on mass
media-radio. Knowledge on the benefit of EBF practice was most in mothers of age
group- 20-24 years. There is a wide gap between knowledge and practice of
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exclusive breast feeding among mothers in Yola South Community. There is an
urgent need for more programs aimed at promoting exclusive breastfeeding as well
as educating and re-educating health personnel and the general public.
Key words: Exclusive breastfeeding, knowledge, practice, infant nutrition
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TABLE OF CONTENTS
Title page ……………………………………………………………………………………….. i
Certification…………………………………………………………………………………… ii
Readers’ approval………………………………………………………………………….. iii
Dedication ……………………………………………………………………………………. iv
Acknowledgement……………………………………………………………………….. v-vi
Abstract ………………………………………………………………………………….. viii-ix
Table of contents ………………………………………………………………………… x-xi
List of tables………………………………………………………………xii
Abbreviations …………………………………………………………………………….. xiii
1.0 Introduction ……………………………………………………………………………… 1
1.1 Definitions of terms …………………………………………………………. 2
1.2 The historical context of breastfeeding ………………………………. 4
1.3 Exclusive breastfeeding trends around the World ………………… 6
1.4 Benefits of exclusive breastfeeding to infants and mothers …… 8
1.5 Strategies for breast feeding promotion……………………………… 10
1.6 Socio-economic benefits of breastfeeding …………………………. 13
1.7 Challenges to breastfeeding ……………………………………………… 16
1.8 Factors that contribute to low rates of breast feeding in
Adamawa State. ……………………………………………………………… 19
1.9 Specific Aims, current study, or objectives ……………………….. 21
2.0 Material and methods ………………………………………………………………. 23
2.1 Introduction ………………………………………………………………….. 23
2.2 Study area …………………………………………………………………….. 23
2.3 Sampling technique ……………………………………………………….. 24
2.4 Study area visitation and pilot test ……………………………………. 25
2.5 Data collection ………………………………………………………………. 25
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2.6 Analytical technique ………………………………………………………. 25
2.7 Limitations ……………………………………………………………………. 27
3.0 Results …………………………………………………………………………………… 26
4.0 Discussion ……………………………………………………………………………… 36
5.0 Conclusion …………………………………………………………………………….. 43
5.1 Recommendation …………………………………………………………… 44
References ………………………………………………………………………… 46
Appendix ………………………………………………………………………….. 50
xii
LIST OF TABLES
Table 1 shows Age Range, Marital Status and educational level of mothers …….. 27
Table 2 Shows parity and occupation of the Mothers …………………………………….. 28
Table 3 shows Mother’s understanding of Exclusive Breastfeeding ……………….. 29
Table 4 shows the benefits of breastfeeding to both baby and mother….. ……….. 31
Table 5 shows Exclusive Breastfeeding rates according to age range, marital status
and level of education among mothers…………………………………………………………. 32
Table 6 shows exclusive breastfeeding rate according to parity and occupation of
mothers ……… ……………………………………………………………………………………….. 34
Table 7 shows the reason why exclusive breast feeding is not practiced by some
mothers.. …………………………………………………………………………………………………. 35
xiii
LIST OF ABBREVIATIONS
EBF: Exclusive breastfeeding
EAF: Exclusive Artificial Feeding
HIV: Human Immunodeficiency Virus
MDG: Millennium Development Goals
UNICEF: United Nations Children’s Fund
WHO: World Health Organisation
1
CHAPTER ONE.
INTRODUCTION AND BACKGROUND
1.0 Introduction:
Over several decades; there has been increasing interest in the promotion of
exclusive breastfeeding as the ‘best’ feeding method for infants. If all babies in the
World were breastfed exclusively, about 1.5 million lives would be saved annually.
Not only would they survive but their lives would be greatly enhanced as well. This
is because breastmilk is the best food for the first six months of a baby’s life and no
formula or product can ever replace it. All children benefit from being breast fed
regardless of their geographical location and breastmilk is composed of all the
necessary nutrients needed for babies to grow up healthy and strong. In resourcelimited areas, poor breastfeeding practices usually results in child malnutrition which
is a major cause of more than half of all child deaths (Sokol et al. 2007), exclusive
breastfeeding is regarded as imperative for infants’ survival. Of the 7 million under
five children who were reported dead globally in 2011, an estimated 1 million lives
could have been saved by simple and accessible practices such as exclusive
breastfeeding (WHO, 2012). Consequently, the (WHO and UNICEF 1990) have
recommended exclusive breastfeeding for six months, followed by introduction of
complementary foods and continued breastfeeding for 18 months or more.
2
Breastfeeding is an ultimate biological and cultural phenomenon; in humans, it is not
only just a biological process but also a culturally determined behavior (StuartMacadam and Dettwyler, 1995: pp.5-6). In Nigeria, about 97% of children begin
breastfeeding from birth and continue to four (4) months (National Demographic and
Health Survey, 1990). By 12 months, the proportion of children exclusively breastfed
is higher in Uganda than in Nigeria. Ugandan children less than six (6) months of
age, approximately 57 percent are exclusively breastfed compared to approximately
1 percent of Nigerian children. (WHO, 1996). The benefits of exclusive
breastfeeding are numerous. Breastfeeding, a primary means of promoting and
supporting good nutrition in developing countries, is universally high in Nigeria;
however, exclusive breastfeeding during the first 6 months of life as recommended
by the World Health Organisation (WHO) is far less common. According to the
National Demographic and Health Survey (NDHS, 1990, only 38 percent of women
in Nigeria initiated breastfeeding within the first hour of delivery and less than onefifth (17 per cent) of infants under 6 months of age are exclusively breastfed.
1.1 Definition of terms:
Breastfeeding: – Is the practice of feeding an infant, or sometimes a toddler
or a young child, with milk produced from her mammary glands, usually directly
from the nipples.
Colostrum: Colostrum is the first fluid that comes from the breast
immediately after birth. It is yellowish in color and contains high protein and antibodies. It is often described as the first form of ‘immunization’ for a new born child.
3
Exclusive breastfeeding: refers to when infants are not given any other food
or liquid including water during the first six months after delivery.
Exclusive artificial feeding: a feeding method that solely involves the use of
none breast milk foods.
Lactation: is the period during which a woman produces milk from the
breasts to feed a baby.
Malnutrition: is a poor condition of health caused by a lack of food or a lack
of the right type of food.
Predominant or mixed breastfeeding: – Is the practice of feeding breast
milk along with some form of substitute.
Prelacteal feeds: Prelacteal feeds are fluids given to newborns before
breastfeeding is initiated.
Postpartum: the immediate period after child birth especially the first 6
weeks.
Stunting: it is also referred to as ‘shortness’. It is a condition characterized
by low height for age that is caused by insufficient nutrition over a long period and
regular infections.
Wasting: this is also known as ‘thinness’. It is a condition characterized by
low weight for height that is caused by acute food shortage.
Weaning: this refers to a practice in the course of breastfeeding during which
infants are
4
gradually introduced to non-breast milk foods and thereby leading to cessation of
breastfeeding.
Wet nurse: a woman who breastfeeds another woman’s baby. In addition to
the feeding, a wet nurse may also be tasked to take care of the baby usually for a fee.
1.2 The historical context of breastfeeding:
All hominoids have similar distinct features of their reproductive features
including the process of lactation and breastfeeding (Kennedy, 2005); yet
anthropologists’ work has been scanty (Sellen, 2009), this is partly due to the maledominated researches that have focused predominantly on male activities neglecting
female related ones such as breastfeeding and childbirth (Stuart-Macadam and
Dettwyler,1995). However; breast feeding has been reported as an age-old process
that is concerned with the structure, function and well-being of neonates as well as
the health of the mothers. There is no society that exists without some form of infant
breastfeeding; as it is one of the human practices that have transcended through time
and place. This has been a method of feeding which has been ingrained in our DNA
and upon which the human existence is based on. For several centuries, breast
feeding has been significantly practiced, respected, and the primary attractor of many
artistic works such as paintings, drawing, and sculptures (Tonz, 2000; Sellen, 2009).
In most ancient societies, breastfeeding practices are principally guided by
traditions, religious literature; etc. Besides, early religious scriptures such as the
Bible and the Quran also had and still have some recommendations on breastfeeding
practices. In Isaiah chapter 66 verse 11, it is mentioned ‘that ye may suck, and be
satisfy with the breast of her consolations; that ye may milk out and be delighted
5
with the abundance of her glory’ (Bible, the book of Isaiah 66:11). The Quran
similarly stipulates that ‘the mothers shall give suck to their children for two whole
years, (that is) for those parents who desire to complete the term of suckling…….
And if you decide on a foster suckling-mother, there is no sin on you, provided you
pay the mother what you agreed on reasonable basis’ (Quran 2:233). Indeed, until the
19th century, breastfeeding was the norm in virtually all human societies; and almost
every child was breastfed regardless of sociocultural environment and economic
status (Soko et al. 2007). Even when mothers were not in a position to breastfeed
owing to sickness, death, e.tc other women were made to breastfeed the newborn.
Over time, these women, called wet nurses became readily and widely available for
breastfeeding services especially for affluent families. In the 19th century, Justus
Von Liebig, a German chemist invented one of the first breast milk substitutes. The
milk produced by Nestle quickly flourished and by 1873, an estimated 500,000 boxes
was sold annually over Europe, USA, Mexico. Beginning with the wealthy and then
poor working mothers, the use of breast milk substitute became widespread,
following extensive advertisements and closed door meetings with medical
practitioners. As a consequence, many mothers were commonly diagnosed with
‘insufficient breast milk syndrome’ and then asked to cease breastfeeding (Avishai,
2009). Almost immediately, breastfeeding rates dropped throughout Europe and
North America as commercial milk gained dominance from late 19th century to the
better part of the 20th century. It is important to note that while wet nursing
coexisted and provided alternative to maternal breastfeeding with little or no harm,
the invention of modern breast milk substitute by contrast, undermined and disturbed
the bond between infants and the very act by means of which they subsisted for
centuries.
6
Around the early part of the 20th century, rising concerns about the risk of
commercial infant milk led to improvements in artificial milk. Sterilization, hygienic
storage facilities, and knowledge about the energy requirements for infants made
breast milk substitutes a relatively safer alternative (Crowther, Reynolds and Tansey,
2009). But even so, artificially fed babies were more disposed to diseases and health
problems compared with the breastfed ones. In Boston for instance, a study in 1910
reported a six fold likelihood of death among artificially fed babies than the breastfed
ones (Palmer, 2009).
1.3 Exclusive Breastfeeding Trends around the World:
Majority of infants born in the United States were breast fed until 1950. In the
past five decades; infant feeding has changed dramatically. Proceeding the Second
World War; development and large scale production of formula has increased and
replaced the practice of breastfeeding. Breastfeeding trends has halved between 1946
and 1956, and by 1967, only about 30 percent of infants in America were being
breastfed after birth. The percentages of breastfed infants have increased rapidly; 62
percent in 1982, dropped to 16 percent in 1990 and rose to 65 percent in 1998.
Reasons new mothers may avoid breastfeeding may include; increase in formula
marketing, lack of support from friends and family, inadequate provision of breast
feeding information by medical professionals, religious beliefs, cultural practices and
public discrimination( Wamani, 2005). Many of these factors affect the practice of
breastfeeding; working and employment of mothers also contribute to the decline in
breast feeding trends.
Nigeria’s estimated population of 120 million in 2002 (National Population
Census, 1991) makes it the largest country in sub-Saharan Africa and the tenth most
7
populated country worldwide. Nigeria’s population is composed primarily of rural
occupants of about 63.7 percent. Currently, about 45 percent of Nigeria’s total
population is less than age 15, with about 20 percent (24 million) under age five.
These large numbers, demand that child survival issues be placed in the forefront of
the national agenda and taken very seriously. Despite its wealth of human and natural
resources, Nigeria is among the 13 poorest countries in the world; two of every three
Nigerians (66%) live below the extreme poverty line of US$1 a day (World Bank,
2001). Nigeria’s low gross national product (GNP)—per capita of $310 in 1998—is
lower among people living in rural areas, limiting their access to adequate nutrition,
quality health care, and other basic social services, especially among vulnerable
groups (women and children) (World Bank, 1999; UNICEF, 1999). According to
various research reports, Nigeria has one of the worst child indices with unacceptably
high infant and under five mortality rates in the world. Data from the Multiple
Indicator Cluster Surveys (MICS 2011) revealed that the infant mortality rate (IMR)
is 97/ 1000 live births and children under five years mortality of 158/ 1000 live
births. Although Nigeria is committed to the achieving Millennium Development
Goals of reducing infant and under five year mortality by two-thirds by the year 2015
however, the country is far from reaching this goal. Along with breast milk, 34% of
infants aged 0–5 months are given plain water only, 10% are given non-milk liquids
and juice and 6% are given milk formula. Furthermore, 35% of infants aged 0–
5months are given complementary foods. This explains the high incidence of infant
malnutrition and mortality experienced in developing countries which is mainly due
to poor infant feeding practices. Efforts made in improving infant and young child
feeding practices in the developing world has been remarkably slow.
8
According to MICS 2011, 24% of children under the age of five are
underweight, 36% are stunted and 10% are wasted. The Exclusive breast feeding rate
for Nigeria is 15% as compared to at least 28% in Adamawa State and about 57% of
new born babies receive prelacteal feeds after delivery. About 21% of children less
than 6 months of age are stunted (NDHS, 2008). Therefore, the promotion and
practice of proper infants and young child feeding by mothers and families at
community level is very important to preventing under nutrition, stunting, wasting
that will results to malnutrition as an underlying cause to high prevalence of child
morbidity and mortality.
1.4 Benefits of exclusive breastfeeding for infants and mothers:
Breastfeeding is the most ideal method of providing ideal food for the healthy
growth and development of infants. It is also a fundamental part of the reproductive
process with fundamental implications for the health of mothers. Breastfeeding
served and continues to serve as an appropriate method through which newborns are
offered essential nutrients necessary for optimal growth and intellectual
development. Breast milk is regarded as ideal, natural and protective food for
newborns. Given that prolonging people’s lives (by reducing mortality) and
preventing disease (by reducing morbidity) are some of the goals of public health
(Brulde, 2011), breastfeeding or exclusive breastfeeding has been recognised as an
efficient advance to the achievement of these goals. In a study by (Vennemann et al,
2009) breastfeeding was found to be protective against sudden infant death syndrome
by reducing the risk by 50% at all ages during infancy. Infants when exclusively
breastfeed for the optimal duration of six months are considerably protected against
the major childhood diseases conditions viz. diarrhoea, gastrointestinal tract
9
infection, allergic diseases, diabetes, obesity, childhood leukemia and lymphoma,
inflammatory and bowel disease (WHO, 2012; American Academy of
Pediatrics,2012). In particular, the risk of hospitalization for lower respiratory tract
infections during the first year of life is reduced by 72% when infants are exclusively
breastfed for more than 4 months (American Academy of Pediatrics, 2012, p. 828).
(Duncan et al .2009, p. 867) also found exclusive breastfeeding to be protective
against single and re-occurring incidences of otitis media. Infants who were given
supplementary foods prior to 4 months had 40% more episodes of otitis media than
their counterparts. Breast milk promotes sensory and cognitive development, and
protects the infant against infectious and chronic diseases. Exclusive breastfeeding
reduces infant mortality due to common childhood illnesses such as diarrhoea or
pneumonia, and helps for a quicker recovery during illness. These effects can be
measured in resource-poor and affluent societies (Kramer et al, 2001). Breastfeeding
contributes to the health and well-being of mothers; it helps to space children,
reduces the risk of ovarian cancer and breast cancer, increases family and national
resources, is a secure way of feeding and is safe for the environment (WHO, 2001).
Breastfeeding reduces the mother’s risk of fatal postpartum hemorrhage and
premenopausal breast and ovarian cancer. Frequent and exclusive breastfeeding
contributes to a delay in the return of fertility and helps protect women against
anemia by conserving iron. Breastfeeding provides frequent interaction between
mother and infant, forging emotional bonds, a sense of security, and stimulus to the
baby’s developing brain (WHO, 2001).
Studies have revealed that children who were breast fed for at least a year
have higher IQ (Intelligence Quotient), completed more schooling and earned more
10
than those who were not breastfed. Although this information has been handy for
years; the study published in The Lancet Global Health has made the strongest link
between intelligence in adults and duration of breast feeding. The researchers studied
about 3500 children over a period of thirty years and according to the coordinator,
Dr. Holly Philips; kids who were breast fed for up to a year had four points higher in
their IQ than those who weren’t breastfed for that long. The study also showed that
children who were breast fed stayed longer in school and earned higher income as
they grew up. Researchers also revealed other factors that could affect IQ such as
birth weight of children, level of mother’s education, socio-economic status; to
mention but a few. Previous studies conducted to determine the relationship between
breastfeeding and IQ focused on families in high income areas and so it wasn’t clear
if this would hold up in more socio-economic diverse areas but the Brazilian study
proved it although the principal reason is still unclear. However; according to Dr.
Phillips, both the breastmilk and the process of breastfeeding contributes to the
development of IQ. While we know that breast milk has numerous nutrients that
support and enhance the development of the brain and nervous system;
communication and bonding between mother and child takes place during breast
feeding and this changes the brain physically and neurons are able to connect with
one another. This increases IQ and boosts confidence which helps in achievements
later in life.
1.5 Strategies for breast feeding promotion:
There have been many strategies that have been applied to encourage the
concept of breastfeeding. Some of these strategies encourage exclusive
11
breastfeeding, some encourage duration while others are concerned with the
initiation. These strategies include:
(i). Structured education Programs:
These are commonly called antenatal classes and are usually started by
pregnant women during the third semester. Topics discussed during these classes
includes positions of breastfeeding, issues surrounding breastfeeding such as sore
breast, feeding in public, mastitis and ways to balance breastfeeding and being a
working mother. The mothers are provided with awareness tools such as booklets
and pamphlets that illustrate the benefits of breastfeeding. These programs focus
primarily on initiation.
(ii). Education programs with support:
These programs offer both education and support for new mothers in one-onone sessions either in the hospital or after she goes home with visitations or phone
calls. These programs run for about three months after birth and it focuses on the
continuation of breastfeeding. The mothers have counselors that they can contact at
all hours to ask questions about such issues as nipple soreness, fussy babies and
frequent feeds. This program is better than the first because it is provided on a oneon-one basis and mothers are able to spend more time with breastfeeding experts
who will talk to them regularly, help in post-natal care and support the mothers both
physically and emotionally. Education and support programs focus on increasing
rates of both breastfeeding initiation and duration.
12
(ii). Peer support or counselling programs:
This involves pairing volunteers with breastfeeding experience with new
mothers so they have support in the first few weeks of birth. They are provided with
educational support relating to breastfeeding practice, emotional support and they are
provided with feedbacks on how to facilitate breastfeeding. This program is based on
the presumption that support from a woman with breastfeeding experience is an
effective way of increasing the chances that women will breastfeed for longer
periods of time and be more satisfied with the process. Peer support or counselling
programs are specifically focused on increasing the duration of breastfeeding. It
relies on selecting volunteers who have had a positive breastfeeding attitude and they
need to be trained to provide support and appropriate referrals. To increase the
success of the counselling programs; the volunteers are matched to the mothers
accordingly with respect to their age, socio-economic status, educational background
and cultural background.
(iv). The Baby Friendly Health Initiative (BFHI):
This organisation is the work of the WHO and UNICEF and has been
implemented in hospitals throughout the World. The BFHI was built on ten steps all
of which are implemented in all maternity wards. The BFHI is a program designed to
increase both breastfeeding initiation and duration but is likely to have an influence
on initiation only.
The ten steps are;
• A written breastfeeding policy that is regularly communicated to all health
care staff.
13
• All health care staff are trained in skills necessary to implement this policy.
• All pregnant women are being informed about the benefits and management
of breastfeeding.
• Mothers are taught to initiate breastfeeding within 30 minutes of giving birth.
• Mothers are shown how to breastfeed and maintain lactation even if they are
separated from their infants.
• Newborn infants are given no food or drink other than breastmilk unless
medically indicated.
• Mothers are encouraged to remain together 24 hours a day.
• Breastfeeding on demand should be encouraged.
• No artificial treats should be given to breastfeeding infants.
• Foster the establishment of breastfeeding support groups and new mothers
should be referred to them on discharge from the hospital.
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