ABSTRACT
Exclusive breastfeeding (EBF) practice have been a serious public health concern,
not only in Nigeria but in the world at large. It have severally been reported that there
is low practice and awareness of EBF in Nigeria. I evaluated the variation in the level
of knowledge of exclusive breastfeeding between mothers in Yola and those in
Fufure IDP camp as well as their perceptions towards its practice. I also assessed the
most effective medium of awareness for the knowledge of exclusive breastfeeding
among the respondents. I used a targeted study design and convenience sampling
method, which is a non-probability sampling technique. My total sample size was
220. The results showed that respondents have high degree of awareness of EBF
(90.9%) and thus most of them practice it (70.4%). Clinical sessions appeared to be
the most effective source of promoting EBF awareness as most of the respondents
(60.1%) learned about it there. Finally, the result of this study have contradicted
many other relevant studies because it revealed that there is so much knowledge and
awareness of EBF among mothers in Adamawa state. Although, there is already a
viii
great deal of awareness of EBF in Adamawa state that are developed by the state
health care units through antenatal and postnatal sessions, media would also be a
great medium to promote EBF awareness in the state.
ix
TABLE OF CONTENTS
CERTIFICATION …………………………………………………………………………………………. ii
READER’S APPROVAL……………………………………………………………………………….iii
DEDICATION……………………………………………………………………………………………… iv
ACKNOWLEDGEMENTS…………………………………………………………………………….. v
ABSTRACT………………………………………………………………………………………………… vii
LIST OF TABLES …………………………………………………………………………………………. x
LIST OF FIGURES ……………………………………………………………………………………… xi
CHAPTER ONE …………………………………………………………………………………………. 1
INTRODUCTION ………………………………………………………………………………………… 1
Malnutrition …………………………………………………………………………………………………. 2
Breastfeeding ………………………………………………………………………………………………… 5
Exclusive breastfeeding ………………………………………………………………………………….. 7
Early initiation of EBF …………………………………………………………………………………. 12
Baby-friendly hospital initiative …………………………………………………………………….. 13
HYPOTHESES …………………………………………………………………………………………… 15
AIMS & OBJECTIVES ……………………………………………………………………………….. 15
CHAPTER TWO ………………………………………………………………………………………. 17
MATERIALS & METHODS ……………………………………………………………………….. 17
CHAPTER THREE …………………………………………………………………………………… 20
RESULTS ………………………………………………………………………………………………….. 20
CHAPTER FOUR………………………………………………………………………………………. 27
DISCUSSION …………………………………………………………………………………………….. 27
CHAPTER FIVE ……………………………………………………………………………………….. 35
CONCLUSION …………………………………………………………………………………………… 35
APPENDIX I……………………………………………………………………………………………….. 36
APPENDIX II ……………………………………………………………………………………………… 41
APPENDIX II ……………………………………………………………………………………………… 42
REFERENCES ……………………………………………………………………………………………. 44
x
LIST OF TABLES
Table 1: Plain water is the liquid that is given to infants in the first four months of life
even much more than breast milk ………………………………………………………………….. 11
Table 2: Health workers are the primary reason why mothers give their infants glucose
water and other PLFs ……………………………………………………………………………………. 11
Table 3: This table has shown that respondents of this study largely learnt EBF for
antenatal sessions at the clinics………………………………………………………………………. 24
Table 4: Of the respondent in this study, most believed that clinical sessions were the
best place in which to promote EBF awareness. ………………………………………………. 24
Table 5: of the respondents in this study, most of those that support and have EBF
knowledge are from Fofure IDP camp. However, the result was insignificant (
2 =
1.04, df = 2, p = 0.59)……………………………………………………………………………………. 25
Table 6: The result below was significant (
2 = 5.8, df = 1, p = 0.01) and it has showed
that knowledge of EBF have significant influence over supporting its practice ……. 25
xi
LIST OF FIGURES
Figure 1: Malnourished African children ………………………………………………………….. 2
Figure 2: Stunting prevalence is highest in sub-Saharan Africa and south Asia. Map
shows percentage of children under age 5 who are moderately or severely stunted … 3
Figure 3: Children with different types of Undernutrition Malnutrition looks. Wasted
children usually look very thin and tall. Stunted children look shorter than there age
and wasted/stunted children look both shorter and thinner than their age has showed
that knowledge of EBF have significant influence over supporting its practice ……… 4
Figure 4: Map of Nigeria showing the location of Adamawa State in the northeastern
region. ………………………………………………………………………………………………………… 17
Figure 5: The frequency of the respondent’s children that died at different age
category. Children that died below the age of one are much higher ……………………. 20
Figure 6: The level of education among the study respondents and the graph is showing
that most of the respondents obtained primary school level education ………………… 21
Figure 7. Most respondents were skill-based workers or housewives………………….. 22
1
CHAPTER ONE
INTRODUCTION
Given the high prevalence of malnutrition in Africa, Exclusive Breastfeeding (EBF)
offers a fool proof method to deter stunted growth and development in the African
subcontinent. Malnutrition has been identified to be the direct cause of about 300,000
deaths every year and indirectly the cause of about half the deaths among young
children in Africa (Müller et.al, 2005). Hence, the need for exclusive breastfeeding
as the first stage of nutrition is the as a way to prevent malnutrition.
The early first years of a child’s life is the most vital and delicate period of
development. It is the stage at which a healthy child goes through rapid development,
psychologically and physically. A child at this stage needs good nutrition for his or
her physical, mental, and immune system development. Moreover, it is at this stage
that the comprehension and sensation potentials of a child begin to develop, as well
as the base of intellectual, social, and emotional competencies of the child
(Michaelsen et al, 2003). Sadly, due to the level of poverty in sub-Saharan Africa,
most children at this stage in the region are prone to poor nutrition (Bain et al.,
2013).
Poor nutrition, or malnutrition, results in growth abnormality and easy contraction of
infectious diseases due to a weak immune system that is caused by the disease. It
also causes problems such as deficiency in learning, lack of development of social
skills, behavioral abnormality, and defects in educational achievement (Michaelsen
et al., 2003).
2
MALNUTRITION
Figure 1: Malnourished African Children. (Credit: Bilkis Ogunnubi, 2016)
Malnutrition is defined as the lack of enough, too much, or unbalanced energy and/or
nutrients in a person’s diet (WHO, 2017). There are three types of malnutrition:
undernutrition, micronutrient related malnutrition, and overweight/obesity (WHO,
2017).
Undernutrition is the deficiency or lack of energy and nutrients in the body which
results in stunted growth, wasting, or underweight. Wasting is having severe low
weigh for height of the body. It indicates lack of enough food or reoccurrence of
diarrhea (WHO, 2017). Stunted growth is having low height for the age of a person.
It indicates persistent undernutrition and it is often related to deficiency in maternal
health, recurrent illness or poor feeding during infancy.
Stunting deprives children from attaining their deserved physical size. Studies have
shown that stunting is prevalent in sub-Saharan Africa and Asia.
3
Figure 2: Stunting prevalence is highest in sub-Saharan Africa and south Asia. Map shows
percentage of children under age 5 who are moderately or severely stunted (credit: UNICEF
Global Nutrition Database, 2012).
About 25 percent of children in the world are stunted, and most of them are from
sub-Saharan Africa. This region is reported to have about 38 percent world’s
reported incidence of stunted growth (UNICEF, 2016). However, the Multiple
Indicator Cluster Survey (MICS) and Demographic and Health Survey (DHS)
reported that the nutrition status of Nigeria’s children had been gradually improving
over the past few decades, reducing from 41 percent in 2008 to 36 percent in
2011(DHS, 2013). The target of WHO is to reduce or eliminate the percentage of the
stunted growth cases to 3.9 percent by 2025 (UN, 2012).
On the other hand, underweight is having low weight for the age of a person or child
and it can be caused by wasting, stunting or both of the diseases (WHO, 2017).
The figure below shows the physical characteristics of children with undernutrition
malnutrition looks like. It has the image of how a normal child is expected to look
like and as well how children with the diseases look like.
4
Figure 3: Children with different types of Undernutrition Malnutrition looks. Wasted
children usually look very thin and tall. Stunted children look shorter than there age and
wasted/stunted children look both shorter and thinner than their age (Credit: Bradly et. al,
2009)
Micronutrient related malnutrition is defined as having insufficient vitamins or
minerals in the body. Micronutrients such as iodine, vitamin A, zinc, iron and
calcium are crucial substances that the body uses to produce enzymes and hormones
for growth and development (WHO, 2017). Thus, lack of these nutrients in the body
stops the body from proper growth and causes diseases such as scurvy (deficiency of
vitamin C) and rickets (deficiency of vitamin D).
Overweight/obesity is defined as having weight that is heavier than is healthy for the
height of the body. An overweight or obese child has excess fat accumulated in his or
her body and this leads to cardiovascular diseases and type II diabetes amongst other
diseases. However, there is a slight difference between overweight and obesity and
this can be determined only by measuring the body mass index (BMI). The BMI is
generally used for adults; it is a number that is calculated to find a person’s weight
with his or her length and height. When plotted in a graph, it is commonly used as a
5
growth indicator against a child’s age. BMI is calculated by dividing the weight in
kilograms by the squared height in meters, i.e. Weight (kg) / Height2
(m) (WHO,
2008).
Despite the rapid economic development and concerted efforts to curb malnutrition
among infants and mothers, little or no progress has been observed in the developing
countries (Gillespie et al., 2003). However, the first stage of ensuring a child’s good
nutrition is the ability of the child to be well breastfed. Breastfeeding is the feeding
of babies and young children from a woman’s breast, which gives the child the
maximum benefits of breast milk (Tyndall et al., 2016). Breast milk is milk that is
highly nutritious, which helps a child maintain healthy growth.
BREASTFEEDING
Breastfeeding is the first stage and the most effective level of primary nutrition.
Breastfeeding improves the four aspects of health: mental, spiritual, physical, and
social (Bonomi et al, 2000). It not only improves infants’ health, but it is also
beneficial to the mother. It delays the menstrual cycle of a mother, which protects her
from early pregnancy (Tyndall et al., 2016).
Early breastfeeding of an infant helps in improving the child’s psychological and
physical health, as well as improving the child’s immune system (National Resources
Defense Council, 2001). The benefits of breastfeeding are numerous. The human
milk glycans contain oligosaccharide, which helps in the formation of natural
immunological mechanism. This helps to protect children against infectious diseases
(Lamberti et al, 2011). Breast milk also helps decrease the level of contact with
6
contaminated foods and drinks that might result in the contraction of diseases.
However, in order for an infant to get maximum benefits of breast milk, the mother
must have an adequate diet. Malnutrition in mothers increases the level of risks that a
mother would face during pregnancy and delivery. Such risks include high level of
and maternal infant mortality and morbidity, insufficient provision of breast milk,
and premature birth (Ransom and Elder, 2003).
The use of contaminated water can lead to serious infections and gastrointestinal
diseases. It has been reported that drinking water is the primary cause of microbial
pathogens in developing countries. Additionally, gastrointestinal diseases are also
more frequent in the countries due to lack of intervention strategies and undernutrition (Ashbolt, 2004). It has also been reported that poor water quality, hygiene
and sanitation account for the death of a1.7 million people worldwide and it is
mainly through diarrhea (Ashbolt, 2004). However, nine out of each death is among
chi1dren and a1most a11 the death incidence happens in deve1oping countries
(Ashbolt, 2004).
In Nigeria, 5.5 percent of reproductive women are malnourished, while about 2.5
percent of them are extremely malnourished. As a result of the high level of poverty
in the northeastern part of Nigeria, the highest percentage of the malnourished
women are from the northeastern region of the country, whereas the southeastern
region has the lowest percentage of the malnourished women (DHS, 2013).
Due to the extreme importance of breastfeeding to both a mother and her baby, WHO
recommends that children are breastfed from the first hour of life to at least six
7
months without introducing any supplement, not even water; this is a practice called
exclusive breastfeeding (WHO, 2012).
EXCLUSIVE BREASTFEEDING
According to the World Health Organization (2001), “Exclusive breastfeeding is
defined as the exclusive breastfeeding of infants for the first six months of life
without the introduction of any food supplement, not even water, apart from Oral
Rehydration Solutions (ORS) drops or syrup that may be required for medication.”
Exclusive breastfeeding (EBF) has reduced child mortality by eliminating or
reducing the incidences of gastrointestinal diseases (Huffman & Combest, 1990;
Young et al., 2011), ear infections, and respiratory diseases amongst children that
were breastfed exclusively up to six months (Tyndall et al, 2016). It also speeds up
maternal weight loss and delays the return of the menstrual cycle (WHO, 2011).
From 2006 to 2010, on average, only 37 percent of mothers globally practiced
exclusive breastfeeding (UN, 2012). Also, only 17% of mothers practiced EBF in
Nigria. By 2025, WHO’s target is to have countries increase the rate of exclusive
breastfeeding up to fifty percent of the general population (UN, 2012).
WHO suggests that all children are required to be exclusively breastfed for the first
six months of age and at least for the first four months of life (WHO, 2012). In 2001,
the effects of exclusive breastfeeding for 6 months vs. 3-4 months were studied in
order to find out the difference between EBF for 6 months and months less than 6.
The research resulted in endorsement for supporting and encouragement of exclusive
breastfeeding up to six months of age. This is because the study found out that
8
children that are exclusively breastfed turned out to be more healthy and energetic
(Lamberti et al., 2011). The study also found that morbidity and mortality are also
related to partial exclusive breastfeeding (WHO, 2001).
In countries with high levels of infectious diseases, it is recommended that a child
should be breastfed for two years (WHO, 2011). This is because children in the
regions are vulnerable to infectious diseases due to the unhealthy conditions of the
environment they live in, but if the children are breastfed up to two years, the risk of
them contaminating disease is lower. WHO also recommends that every country
should support and promote breastfeeding by achieving the four targets that are
outlined in the Innocenti Declaration. The four targets are having a national
coordinator of breastfeeding, practicing the Baby-Friendly Hospital Initiative,
initiating the international code of marketing breast milk and a law to protect
breastfeeding mothers (UNICEF,1990). Innocenti Declaration was produced and
adopted by participants at the WHO/UNICEF policymakers’ meeting on
breastfeeding in the 1990s, which is a global initiative, co-sponsored by the US
Agency for International Development (A.I.D) (UNICEF, 1990).
Exclusive breastfeeding between the first day to six months is a key child survival
support (Lamberti et al., 2011). Children who are breastfed for 2 years of age have a
lower risk of diarrheal infections and death (Lamberti et al., 2011). However, despite
the extreme importance of the practice of breastfeeding or specifically exclusive
breastfeeding, the percentage of this practice is very low all over the world and most
especially in the developing nations (Lamberti et al., 2011). Forty seven to fifty
seven percent of babies who are less than two months and 25-31 percent of babies
9
who are between 2-5 months in developing countries are exclusively breastfed,
whereas all other babies that are above 6 months of age receive any kind of food
supplement apart from breast milk (Black et al., 2008).
Factors such as culture, beliefs and perceptions, and lack of awareness are
influencing or hindering the practice of EBF. Religious beliefs are one of the factors
that hinder most people from practicing exclusive breastfeeding. Muslim and Hindu
followers are an example of societies that, despite possibly having knowledge of the
importance of exclusive breastfeeding, still consider feeding their babies honey,
dates, and zamzam (a spiritual water that is believed to be from mekkah) (Chagan,
Fayyaz, & Aamir, 2016).
Prelacteal feeds (PLF) are one of the major factors that hinder mothers from
exclusively breastfeeding their babies. PLFs are food supplements that are
administered to babies at the early hour of birth as a result of religious beliefs,
cultural traditions, or lack of breast milk from the mothers’ breast at the early hours
of birth (Chagan et al., 2016). In the Pakistan Muslim societies, for example, the
tradition of administering PLF is called tahneek, which is the process of introducing
a softened date to a baby before taking the first breast milk. This practice is done by
a respected member of a family, and it is believed that the child will be raised to have
the same character as the family member (Chagan et al., 2016). Other reasons for
PLF among these societies include purification of the tummy, lessening of aches,
making excretion easier for the baby, and provision of moisture to the mouth of the
baby before the arrival of milk (Chagan et al., 2016).
10
Studies have shown the harmful effects of practices of PLFs hamper the early
initiation of breastfeeding (Fidler & Costello, 1995). As such, these practices are
harmful to infants unless they are medically prescribed by a doctor (Hossain et al..,
1995).
However, in rural Egypt, PFL use was found to be higher among mothers who
attended clinics and obtained modern training (Hossain et al., 1995). This may be
because health care professionals suggested the introduction of glucose water and
formula milk to the infants for the prevention of hypoglycemia (low blood sugar
levels), and this is done in many parts of the world (Fidler & Costello, 1995).
Additionally, some doctors promote the practice of PLF to prevent or treat
dehydration and newborn jaundice. However, professionals argue that introducing
PLF to avoid disease or dehydration is not sound advice because babies do not need
PLFs, as breast milk is fully sufficient for them (Isenalumhe & Oviawe, 1987).
Insufficient breast milk production by the mothers is, however, one valid reason for
PLF practice (Hossain et al., 1992).
In Nigeria, late commencement of breastfeeding is frequently practiced and is
associated with PLF practices (Cunningham el at., 1991). Almost all mothers (99.8
percent) in southern Nigeria give water to their neonates from the early hour of birth,
and 75.2 percent of them give their neonates glucose water (Nwankwo & Brieger,
2012). However, the influence of health workers, family members, culture, and
personal interests were the major reasons for the introduction of prelacteal foods to
the neonates in the region. Health workers were mainly responsible for
recommending glucose water, whereas grandmothers often recommended herbal tea.
11
Giving babies plain water is mostly due to the belief that the neonates are thirsty
(Nwankwo & Brieger, 2012).
The table below shows the percentage of liquids that are given to infants in the south
and the level of whom the administer it to the infant at each stage of life.
Table 1: Plain water is the liquid that is given to infants in the first four months of life even
much more than breastmilk.
Point/period in time (per cent giving)
Type of fluid At birth first week 1-4 months
Breast milk 86.9% 100.0 100.0
Plain water 99.8% 100.0 100.0
Glucose water 75.2% 71.5% 37.2%
Agbo (herbal tea) 3.6% 47.2% 97.3%
Data source: Brief report journals credit
The table below shows the types of prelacteal liquids that are given to children and
the people that recommend each type of liquid.
Table2: Health workers are the primary reason why mothers give their infants glucose
water and other PLFs
Types of fluids recommended (percent)
People who recommend breast milk plain water glucose water Agbo (herb
tea)
Health workers 71.5% 80.8% 93.7% 3.1%
Grandmother 1.0% 0.5% 0.6% 50.5%
Culture 5.3% 3.9% 0.0% 12.3%
Husband 0.2% 0.2% 0.6% 10.2%
Data source: Brief report journals credit: file:///C:/Users/hp%20dm4/Downloads/480109.pdf
Moreover, most of the mothers who were involved in the study did not have the
knowledge of exclusive breastfeeding; only 45 percent of the mothers had ever heard
of exclusive breastfeeding. Their sources of EBF knowledge were mostly from
primary health care workers, their mothers or mothers-in-law, friends, husbands, and
12
radio/television campaigns. Primary health care workers are the primary
recommenders of EBF. About 94.7 percent of mothers heard about the practice of
EBF from them. The media is the less effective way of informing the mothers about
EBF because mothers that respond to the study who heard about EBF on the radio
were very few. Additionally, the mothers who knew of other mothers practicing EBF
were only 7.5 percent of the total mothers (Nwankwo & Brieger, 2012).
More than half the women involved in the study understood EBF to be of good effect
to their children, whereas most who heard about it for the first time felt it was a bad
idea–believing that children who undergo EBF would not grow well and would be
unhealthy. They believed even if a child were be exclusively breastfed, the child
must also be given agbo (herbal tea) for protection from diseases (Nwankwo &
Brieger, 2012).
EARLY INITIATION OF EBF
The introduction of prelacteal feeds is the reason breastfeeding is not initiated at the
early hour of birth. This practice deprives a lot of babies of the most important
nutrient in breast milk, known as the colostrum. Colostrum is the first breast milk
that is produced immediately after giving birth and it lasts for about two to four days
of the perinatal lactation period (Godhia & Patel, 2013). It is thicker than the normal
breast milk, and contains many nutrients, including protein, growth factors,
immunoglobulin, vitamin K (Kries et al., 1987). Colostrum has twice the nutrients
that normal breast milk has (Tyndall et al., 2016). Many mothers in Adamawa State,
northeastern Nigeria, consider colostrum as stale milk and hence avoid giving it to
their children (Tyndall et al., 2016). Another factor hindering the practice of EBF in
13
this region was that mothers believe the weather of the region makes EBF
inappropriate for their children because the children will become dehydrated
(Tyndall et al., 2016). Adamawa State is a tropical dry land region with average
annual temperatures of 35 degrees Celsius and maximum temperatures of 41 degrees
Celsius between February and May (Bidinger, 1990).
FACTORS/FACILITIES THAT WILL PROMOTE EARLY EBF; BABY
FRIENDLY HOSPITALS
In 1991, WHO and UNICEF instigated the Baby-Friendly Hospital Initiative (BFHI).
The purpose of the initiative is to improve and protect breastfeeding practices. The
initiative took all measures in ensuring that infants are exclusively and well
breastfeed, with about 156 countries implementing the idea (WHO, 2009). The major
target of this initiative is to develop hospitals where the staff will be well trained so
as to train mothers how to breastfeed their children well. One such hospital in Ile-Ife,
Nigeria, found that mothers who had the baby-friendly training breastfed their
children in better ways than those who did not (Ojofeitimi et al., 2000). The initiative
is meant to reach all mothers so that its aim will be achieved, but in Nigeria, the
BFHI program is restricted to tertiary health care units and thus the program does not
reach a large number of families (Ogunlesi, 2004).
Nigeria, with 15 percent level of EBF, is one of the countries with lowest rate of
exclusive breastfeeding (UN, 2012). However, UNICEF has recently reported that
the rate of exclusive breastfeeding is now 25 percent in Nigeria, which is still low
because despite the increase over 5.4 million children are still not getting sufficient
benefits of exclusive breastfeeding. In comparison to Ghana, Nigeria’s increase in
14
the rate of exclusive breastfeeding is extremely slow. In 1994, Nigeria and Ghana
were both at the rate of 7.4 percent EBF but by 2013, Ghana sped up to 63 percent
while Nigeria has remained at 25 percent up to this year (2017) (UNICEF Nigeria,
2016).
Nigeria has the largest population of any African nation and a rapidly growing
population with about 195,510,982 people (DHS, 2018). Considering the many
benefits of EBF and its underuse in Nigeria, I investigated mothers’ knowledge and
attitudes toward EBF in clinics in Yola-Jimeta, Adamawa State, northeastern
Nigeria. I also evaluated the role of awareness programs on affecting attitudes and
opinions toward exclusive breastfeeding. The findings of this study will be shared
with the community, and recommendations will be made to health care facilities in
Yola-Jimeta to increase outreach on exclusive breastfeeding.
The internally displaced people (IDP) are immigrants that are mostly from Maiduguri
who migrated to Adamawa state as a result of the Boko Haram crisis. They are
mostly Kanuri by tribe and they speak both Hausa and Kanuri language. Majority of
the IDPs are Muslim women, young children and old men. There are 390 women in
the camp in which 54 are and 252 are lactating. The total number of children in the
camp is 759. Additionally, most of the IDPs are from Damboa, Gwoza, and Ngala
local government of Maiduguri state.
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