Breastfeeding Awareness and Practices in Abakaliki, Southeast, Nigeria

Background: The Federal Teaching Hospital is the only tertiary hospital in Ebonyi State Nigeria. It receives referrals from the general and private hospitals, primary health centers in the state as well as the surrounding state. Breast feeding is a social norm among the indigenes of the state hence practiced commonly. Aim: The study was aimed at determining the knowledge and practice of exclusive breast feeding among the women presenting in the hospital. Methods: This was a cross-sectional study in the maternity unit of the hospital over three months’ period from March to May 2015. A structured data sheet was administered to each mother presenting in the maternity unit of the hospital and willing to participate which were consecutively recruited into the study. Results: A total of 500 mothers participated in the study. About 98.4% were aware of exclusive breast feeding while 90.2% practiced it for different reasons and duration. Only 76.4% practiced it for a period of 4 6 months. Majority of the mothers (90.0%) got the information about exclusive breast feeding from the hospital. Times of initiation of breast feeding after delivery were 38.2% within 30 minutes and 33.2% an hour respectively. Seventy six percent of the mothers’ breastfed on demand. About 91.6% were willing to practice exclusive breast feeding for subsequent babies. Surprisingly 10.2% of the mothers discarded their colostrums. Practice of exclusive breast feeding was significantly related to educational status and occupation. Conclusion: Greater awareness and practice of exclusive breastfeeding has been achieved but more still needed to be done especially about the time of initiation, giving of colostrums and the duration of exclusive breast feeding since up to 10.4% of the participants still discarded their colostrums particularly those that delivered outside the hospital.


Introduction
Breastfeeding is as old as man and is the safest and best child rearing practice in terms of infant feeding. This practice was being relegated to the background as breast milk substitutes were taking its place. The importance of breastfeeding cannot be overemphasized. The breast milk is hygienic, safe, cheap, readily available and affordable. It supplies all the necessary water and nutrients adequate for healthy growth and development in the first six months of life as well as the necessary immunity for some common infections. It does not place undue stress on the immature intestines, liver and kidneys of the newborn baby. For the breastfeeding mother, it serves as a method of family planning especially when done on demand and exclusive. Studies have shown that breastfed babies are less likely to suffer most serious illnesses [1] [2] [3] [4].
The provision of adequate nutrition during infancy and early childhood is a basic requirement for the development and promotion of optimum growth, health and behavior of the child. Adequate nutrition means intake and utilization of enough energy and nutrients to maintain wellbeing, health and productivity of an individual. The period of birth to two years of age is recognized as a critical period for which adequate nutrition should be provided for the child to achieve optimum development and full potential [5].
The World Health Organization in 2010 reported worldwide prevalence or rate of Exclusive Breastfeeding as 35% from 0 -5 months [6]. The rate of 19.1% was reported in Greece [7], 36% in Bangladesh among rural women and 10% in India [8] [9]. The exclusive breastfeeding awareness in Ethiopia and Tanzania were 93.6% and 58.8% respectively while the prevalence rate in Ethiopia was 59.3% [10] [11].
In Nigeria, the immediate causes of malnutrition in the first two years of life are inappropriate breastfeeding and complementary feeding practices coupled with high rates of infections. About 60% of all childhood deaths are reportedly due to underlying malnutrition [5]. The rate of exclusive breastfeeding in the first six months of life was reported as between 15% to 17% (NFCNS 2001-3, NDHS 2003. Over 50% of Nigerian infants are given complementary food too early which is often of poor nutritional value in terms of energy, protein and micronutrients. Based on these and the innocent declaration as well as the baby friendly initiative adopted in 2005, there was policy development on Infant and Young Child Feeding (IYCF) in Nigeria. The policy is aimed at: 1) Promoting, protecting and supporting exclusive breastfeeding.
Some studies have shown improvement but there is still much work to be done. Currently, scientific evidence overwhelmingly indicates that breastfeeding is the optimal method of infant feeding and should be promoted and supported to ensure the best health for women and children. Breastfeeding is the single most powerful and well documented preventive modality available to health care providers to reduce the risk of common causes of infant morbidity. Significantly, lower rates of diarrhea, otitis media, lower respiratory tract infections, type 1 & 2 diabetes, childhood leukemia, necrotizing enterocolitis and sudden infant death syndrome occur among those who were breastfed [12]. Women who breastfeed have lower risk of type 2 diabetes, breast and ovarian cancers [13]. Recent evidence also suggests that reduction in the risk for cardiovascular and other related diseases may be added to the benefits of breastfeeding for women [14]. Recently breastfeeding has been found to play fundamental role in preventing childhood overweight and development of later obesity. Recent analysis showed that breastfeeding consistently reduced risk for overweight and obesity and that the greatest protection is seen when breastfeeding is exclusive for more than three months [12] [13] [14].
There is no previous study in this center on breastfeeding practices. This study is aimed at determining the awareness and breast feeding practices among mothers presenting at the maternity unit of the Federal Teaching Hospital Abakaliki.

Materials and Methods
This cross-sectional descriptive study was prospectively carried out at the maternity unit of the Federal Teaching Hospital Abakaliki, Nigeria between March and May, 2015. The purpose and methods of the study were explained to the mothers in details and informed consent obtained prior to enlisting them into the study. The exclusion criteria were those that refuse consent and HIV positive mothers.
The study population comprised of consecutively recruited mothers in the maternity unit (postnatal and antenatal wards and antenatal clinic). An open-ended questionnaire designed for the study administered to the mothers. Socio-demographic information including the age of the mothers, maternal occupation, educational status, parity, religion, marital status were obtained. The details of breastfeeding and weaning practices were recorded.

Ethical Issues
The research and ethics committee of the Federal Teaching Hospital approved the study protocol. Informed consent was obtained from the participants and given the option to opt out at any time if they do not wish to continue. Those who do not practice exclusive breastfeeding were counseled adequately on the importance for both the mother and the baby. The importance of colostrums and early initiation of breastfeeding were also emphasized with particular attention to those that discarded their colostrums.

Sample Size Calculation
A similar study in the country reported the awareness of 67.1%. This was chosen to calculate the minimum sample size using the following formula: where n = The required minimum sample size, z = A number relating to the degree of confidence = 1.96, P = The proportion of awareness from a similar study = 67.1%, d = The tolerable error for the study = 5%.
Thus the estimated minimum sample size was 339 but we analyzed 500 clients.
The information obtained was recorded in the data collation sheet designed for the study. The coded data were fed into the computer using epi info program (2008) of CDC Atlanta USA 3.5.1 version and analysis done. A P value less than 0.05 was considered significant.

Results
A total of 500 mothers participated in the study.  Table 2).
Majority of the mothers breastfed as a social norm (72.6%) as well as for healthy growth of the baby (70.0%) ( Table 3). Some of the mothers (19.4%) discontinued EBF because they believe baby remains hungry and 17.8% because of return to work or school but majority of them 76.6% discontinued at the right time (Table 4). Educational status and occupation were the variables that had statistical significant relationship with the practice of EBF (X 2 = 6.0486), P value = 0.0486 and X 2 = 13.2923, P value = 0.0386 respectively) ( Table 5). The mode of delivery has significant relationship with the time of initiation of breastfeeding after birth (X 2 = 120.9952, P value = 0.0000). The place of delivery had statistically significant relationship with discarding of the colostrums (X 2 132.2072, P value = 0.0000).
Educational level also played a significant role in the duration of EBF (X 2 = 27.7582, P value = 0.0000). Age of mother also played a significant role in the total duration of breastfeeding (X 2 = 22.9749, P value = 0.0008) as well as parity (X 2 = 12.3825, P value = 0.0147) and occupation (X 2 = 23.0868, P value 0.0270) ( Table 6).

Discussion
There was high awareness (98.4%) and practice (90.2%) of exclusive breastfeeding among the participants in this study. The awareness was much higher than previous reports from different parts of the country which ranged between 35.9% -71.3% [15] [16] [17]. This shows that more people are becoming aware of exclusive breastfeeding as there is wide spread information available for the mothers. It may also mean that more of the mothers now have access to antenatal care services and skilled attendant at birth who educated them on breastfeeding. This level of awareness may also be because the study was carried out in a tertiary hospital. About 90.2% of the mothers practiced exclusive breastfeeding for different duration, but 76.4% practiced it between 4 -6 months. This is also higher than previous reports from different parts of the country which ranged between 10.2% -61% [16]- [21]. This also may be due to increased awareness and previous experience by the mothers, increased antenatal care and access to skilled birth attendants at delivery. Major source of information was from the hospital (health workers) which was 90.0% and is similar to previous report of 82.1% [15]. The mean age in the study was 29.4 ± 5.4 years. This compares with previous report of 27.4 ± 5.9 years [16]. Age did not show significant association to practice of exclusive breastfeeding. This was different from the previous study which found a significant relationship between age and practice of exclusive breastfeeding [16]. Age however showed significant association with total duration of breastfeeding as older women were more likely to breastfeed for a longer period. They was no significant association between parity and practice of exclusive breastfeeding but was significantly associated with total duration of breastfeeding as the mothers of higher parity were more likely to breastfeed for a longer period. Only occupation and level of education had significant association with the practice of exclusive breastfeeding. This was similar to previous studies [16]. Education also played a very significant role in the duration of exclusive breastfeeding. Mothers with higher level of education were more likely to breastfeed exclusively for 4 -6 months. This may be because they have better understanding of the concept and also use it as a form of post partum contraception.
Only 38.2% of the mothers initiated breastfeeding within 30 minutes of delivery. This is low for a baby friendly facility. This was also lower than previous studies in the country which reported 61% for designated baby friendly hospital and 39% from undesignated hospital [21]. This may be because of the general believe among the mothers that breast milk does not flow soon after delivery. This may also be due to the inclusion of unbooked mothers and those that delivered outside the hospital but presented in the facility for one reason or the other during the study period. It may also be due to exhaustion and discomfort after delivery which proper counseling can take care of. The mode of delivery also played a very significant role on the time of initiation of breastfeeding. Mothers who had spontaneous vertex delivery were more likely to initiate within 30 minutes of delivery.
Some of the mothers (10.4%) still discarded their colostrums for various reasons. This was however lower than previous reports in the country [15]. Some believe it is harmful to baby, dirty and infected. Others believed it is witch milk and is bad so should not be given to the baby. Some were told not to give by their aged mother or traditional birth attendants. The place of delivery played a very significant role in the discarding of colostrums. This was similar to previous reports [15].
Some of the women discontinued exclusive breastfeeding due to various reasons majority of which was at the right time. Some however discontinued because they believed that baby continues to be hungry (17.8%), returned to work or school (17.8%). These were lower than previous reports of 29.0% [19] and 20.8% [16] and 24.0% respectively. This may be because the mothers now know better feeding methods, positions, more are breastfeeding on demand and feeds baby till satisfaction.

Conclusion
Greater awareness has been achieved and more mothers are practicing exclusive breast-feeding.