CHAPTER ONE

INTRODUCTION

1.1 Background of the Study

Exclusive breastfeeding has been defined as feeding of an infant with breast milk only without

giving any other foods, not even water (Jolly, 2015).Infant feeding methods are a major

determinant of infant nutritional status, which in turn, affects infant morbidity and mortality.

Among feeding methods, breastfeeding is of particular importance because this practice is

fundamental for growth, development, health and survival of infants. Diallo, Bell, Moutquine, &

Garrant (2016) stated that about 5.6 million infants die annually because they do not receive

adequate nutrition. Breastfeeding therefore has been classified by scientists and health workers as

the best natural food for babies and breast milk contains all the necessary nutrients for the healthy

growth of the child. The benefits of breastfeeding are numerous ranging from providing the infant

with antibodies, to helping ward off risks of illnesses and providing the baby with all his/her

nutritional needs (Mundi, 2015). According to the World Health Organization (WHO) (2014),

breast milk provides all the energy and nutrients that the infant needs for the first six months of

life, and it provides about half or more of a child’s nutritional needs during the second half of the

first year, up to one third during the second year of life. Furthermore, breast milk not only

protects the infant against infectious and chronic diseases, but also promotes sensory and

cognitive development in addition to contributing to the health and well-being of mothers,

helping in birth spacing, reducing the risks of ovarian and breast cancers as well as increasing

family and national resources (WHO, 2014).

Generally, breastfeeding is practiced all over the world, though with variation in duration.

Considering that the introduction of other food supplements at an early age often increase the

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risks of infections to the infant which may at times lead to life-threatening conditions such as

diarrhea, the WHO and United Nations Children’s Fund (UNICEF, 2014), recommended that

infants be exclusively breast fed for six months and, thereafter, up to 24 months, introducing

other supplements to support the infant’s growth and development. In view of the many benefits

afforded by mothers and infants in breast feeding, governments have also set goals and rates for

breast feeding practices. The Nigerian government has earmarked six University Teaching

Hospitals as Baby Friendly Hospital Initiative (BFHI) centres, in Benin, Enugu, Maiduguri,

Lagos, Jos, and Port-Harcourt, with the objective of reducing infant malnutrition, morbidity and

mortality, as well as promoting the health of mothers. Since the inception of BFHI in 1991, a

series of programmes, seminars, workshops and conferences aimed at promoting breast feeding

practices have been organized. The BFHI itself has proved to be an effective method of

improving breast feeding practices worldwide (Salami, 2016). To further strengthen the practice

of exclusive breastfeeding, governmental so approved a breast feeding policy in 1998. The code

on the marketing of substitutes of breast milk was reviewed and amended in May, 1999, to

further introduce stiffer fines and a clearer definition of breast milk substitutes. These measures

are aimed at increasing the rate of exclusive breastfeeding as well as the early initiation of

breastfeeding so as to achieve the World Summit on Children1990 goal of universal exclusive

breastfeeding for infants up to six months of age (Mundi, 2015).

These measures notwithstanding, evidence showed that the practice of exclusive breastfeeding

(though fast improving) is still low in many parts of the world. In Nigeria, the rate increased from

2% to 20% in infants 0-3 months and from 1% to 8% in infants 4-6 months between 1990 and

1999 (National Planning Commission (NPC)/UNICEF, 2001). The Nigeria Demographic and

Health Survey (NDHS) (2015), however, revealed that 97% of Nigerian children under age five

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were breastfed at some point in their life. A small proportion of infant (13%) were exclusively

breastfed throughout the first six months of life. More than seven in ten (76%) children of ages 6-

9 months received complementary foods. 16% of infants less than six months of age were fed

with a bottle with nipple, and the proportion bottle fed peaked at 17% among infant in the age

ranges of 2-3 and 4-5 months. However, less than half of infants (38%) were put to the breast

within one hour of birth and only 68% started breastfeeding within the first day. Relatively,

among children born in the five year preceding the survey in Nnamdi Azikiwe University

Teaching Hospital, Nnewi, showed that 97.8% of children ever breastfed. 64.1% started

breastfeeding within one hour of birth. 90.2% began breastfeeding within 1 day and 38.7%

introduce pre-lacteal feed. Only 0.5% children were exclusively breastfed. These proportions

indicate a marginal level of decline from the 1990, 1991, 1999, 2013 and the 2015 surveys

(NDHS, 2015).

These dwindling attitudes regarding the practice of exclusive and non-exclusive breastfeeding

have been attributed to several socio-economic, cultural and socio-demographic factors. Thus,

this study purposed to examine the influence of demographic determinants of exclusive and non-

exclusive breastfeeding among nursing mothers in Nnamdi Azikiwe University Teaching

Hospital, Nnewi, Nigeria.

1.2 The Statement of the Problem

Breastfeeding practices have undergone tremendous medical, cultural and sometimes religious

challenges and debate. In an attempt to achieve successful breastfeeding globally by the year

2000, the World Health Organization and United Nations Children’s Fund (1993), launched the

Baby Friendly Hospital Initiative (BFHI) in 1991. The BFHI is a global effort involving 160

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countries, of which 95 of them are in the developing world where Nigeria is inclusive (Salami,

2016). This project is to support, protect, and promote the practice of exclusive breastfeeding for

six months and thereafter until 24 months of age. Several medical literatures have also

established the superiority of breast milk over the other types of milk for the nourishment of the

human infants, offering better health benefits.

Although breastfeeding is universal in the country, the trend is towards giving other feeds in

addition to breast milk. Generally, the practices are more diversified and are characterized by late

initiation of breastfeeding, the administration of substances other than maternal milk, and the

introduction of weaning foods within one month following the infant’s birth. The Nigerian

Integrated Child Health Cluster Survey (ICHCS, 2013), indicated that a major area of need in

infant breastfeeding was early initiation. The survey indicated a decline from 56% in 2000 to

34% in 2002. The Nigeria Demographic and Health Survey (NDHS, 2015) reports, also revealed

a 13% exclusive breastfeeding rate which is a decline from 17% indicated in 2013 report. The

2015 report further revealed that 34% of infants aged 0-5 months were given plain water in

addition to breast milk, while 10% were given milk other than breast milk. Only 32% of infants

under 24 months of age were still on breast milk.

Considering the percentage of mothers practicing breastfeeding, it should not be surprising that

Nigeria is still saddled with high incidence of malnutrition and its associated infant mortality.

Many factors have been adduced to influence these practices. The decisions are very often

influenced more by other factors than by health considerations alone. According to Sika-Bright

(2010), the factors which influence the decision to exclusively or non-exclusively breastfeed

include; mother’s marital status, employment status, friends method of feeding their babies,

social support and baby’s age. Several other demographic studies conducted over the years (i.e

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National Demographic Sample Survey (NDSS), 1966; Nigeria Fertility Survey (NFS), 1982;

National Population Policy (NPP), 1988; Integrated Child Health Cluster Survey (ICHCS) 2013;

Nigeria Demographic and Health Survey (NDHS), 1990, 1999, 2013, &2015; have also identified

similar factors to include; mother’s level of education, occupation, and income level to influence

mother’s choice of exclusive breastfeeding. While significantly expanded in content, the primary

objective of the previous surveys has been on emerging issues such as awareness and behaviour

regarding HIV/AIDS and other sexually transmitted infection, poverty, gender inequality,

fertility, mortality, nuptiality, awareness and use of family planning methods, sexual activity,

nutritional status of mothers and infants, early childhood mortality and maternal mortality,

maternal and child health and of course breastfeeding practices. However, these factors are

apparent in the studies conducted over the years. The existence of a large scale of mothers

practicing exclusive and non-exclusive breastfeeding, and its associated causes remained elusive

in the studies. It is not definite or clear whether demographic factors significantly or

insignificantly influence the practice of exclusive and non-exclusive breastfeeding. It is worthy of

note that up till recently, the principal foci of attention has been demographic factors and the

practice of exclusive breastfeeding. None of the studies conducted over the years concern itself

much with demographic factors and the practice of exclusive and non-exclusive breastfeeding of

babies and in Anambra State using Nnamdi Azikiwe University Teaching Hospital, Nnewias a

case study. Therefore, the study purposed to examine demographic determinants of exclusive and

non-exclusive breastfeeding among nursing mothers in Nnamdi Azikiwe University Teaching

Hospital, Nnewi.

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1.3 Research Questions

This study sought to provide answers to the following specific research questions:

1. Does mother’s age influence the practice of exclusive and non-exclusive breastfeeding of her

baby in Nnamdi Azikiwe University Teaching Hospital, Nnewi?

2. Does mother’s level of education influence the practice of exclusive and non- exclusive

breastfeeding of her baby in Nnamdi Azikiwe University Teaching Hospital, Nnewi?

3. Does mother’s occupation has any impact on the practice of exclusive and non- exclusive

breastfeeding of her baby in Nnamdi Azikiwe University Teaching Hospital, Nnewi?

1.4 Objectives of the Study

The main purpose of this study was to examine demographic determinants of exclusive and non-

exclusive breastfeeding among nursing mothers in Nnamdi Azikiwe University Teaching

Hospital, Nnewi. The specific purposes of the study are:

a) To assess whether mother’s age has influence on the practice of either exclusive or non-

exclusive breastfeeding of babies.

b) To assess whether mother’s level of education influence the practice of exclusive and non-

exclusive breastfeeding of babies.

c) To assess whether mother’s occupation has any impact on the practice of exclusive or non-

exclusive breastfeeding of babies.

1.5 Significance of the Study

The findings of this study would give an insight into areas where health education campaigns are

required to influence and promote the adoption of exclusive breastfeeding. Specifically:

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The findings of the study would benefit employers of labour to plan more appropriately the

period of time for lactating mothers in order that it may not interfere with their work or working

hours.

It would also make progress towards obtaining demographic data on exclusive and non-exclusive

breastfeeding among nursing mothers attending antenatal clinics in Nnamdi Azikiwe University

Teaching Hospital, Nnewi. This, in addition, will benefit nutritionists, health planners in

Anambra State to formulate policies and strategies that are geared towards the promotion of

exclusive breastfeeding on specific group of women and locations in which it is poorly practiced.

The findings of the study would benefit health workers to develop special intervention measures

on specific age ranges of mothers who poorly practice exclusive breastfeeding.

The findings of this study would help health educators, nurses, nutritionists and curriculum

planners to develop informed programmes for nursing mothers on the benefits of breastfeeding.

This in addition, would update the curriculum to educate students in higher institutions of

learning in preparing for future parenthood to adopt an effective method of breastfeeding the

infant.

1.6 Research Hypotheses

Based on the research questions, one major hypothesis and five sub-hypotheses were formulated

for the purpose of this study:

Major Hypothesis

Demographic determinants of nursing mothers do not influence the practice of exclusive and non-

exclusive breastfeeding of babies in Nnamdi Azikiwe University Teaching Hospital, Nnewi.

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Sub-Hypotheses

1.6.1 Mother’s age will not significantly influence the practice of exclusive and non- exclusive

breastfeeding in Nnamdi Azikiwe University Teaching Hospital, Nnewi.

1.6.2 Mother’s level of education will not significantly influence the practice of exclusive and

non-exclusive breastfeeding in Nnamdi Azikiwe University Teaching Hospital, Nnewi.

1.6.3 Mother’s occupation will not significantly influence the practice of exclusive and non-

exclusive breastfeeding in Nnamdi Azikiwe University Teaching Hospital, Nnewi.

1.7 Basic Assumptions

On the basis of research evidence, the following basic assumptions are drawn for the purpose of

this study:

1. That low educational attainment of nursing mothers account for failure to exclusively

breastfeed the infant for up to 4-6 months.

2. That poor working conditions of nursing mothers caused the mother to discontinue exclusive

breastfeeding and introduce other feeds to complement breastfeeding.

3. That babies born to mothers in the highest level of income are less likely to receive a pre-

lacteal feed than babies born to mothers in the lowest level of income.

1.8 Delimitation of the Study

This study is delimited to the followings:

Demographic determinants of nursing mothers such as age, occupation, level of education, level

of income and family/friends views and the practice of exclusive and non- exclusive

breastfeeding of babies in Anambra State. Nursing mothers who attended postnatal clinics in

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Nnamdi Azikiwe University Teaching Hospital, Nnewi.

1.9 Limitations of the Study

The findings of this research must be viewed in line of the limitations of the study. First, the

relationship between types of breastfeeding and the infant mortality and morbidity were probably

underestimated by some mothers as they did not attend post-natal care for further assessment and

possible advice by the health care providers. Such nursing mothers were not included in the

sample of the study. The study considered only nursing mothers that attended postnatal clinics.

The study did not take into account the differences between the infants who were raised by their

biological mothers and those raised by significant others, and this could involve some bias in the

decision to exclusively or non-exclusively breastfeed the infant. Based on this, the researcher

convinced the nursing mothers to provide accurate information on the method they feed their

babies, as this was not to “witch hunt” them but was merely for academic purpose.

Nursing mothers with astute traditional and religious beliefs were difficult to convince to

complete the questionnaire. However, with the help of the nurses on duty, they were assured of

the confidentiality of their responses, as the exercise was mainly for academic purpose.

1.10 Operational definition of terms

Appropriate health seeking behavior- seeking prompt and appropriate care and treatment for

illnesses

Contextual factors - place of child delivery, type of child delivery, breastfeeding support from

family and breastfeeding support programmes/counseling.

Cultural factors – population beliefs, norms and local myths about breastfeeding and infant

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feeding practices.

Exclusive breastfeeding-this means an infant is fed only on breast milk (including milk

expressed from a wet nurse) and allows for medicine, oral rehydration, drops or syrups (vitamins

and syrups) (WHO, 2015).

Informal settlement / slum- Living conditions in which a household lacks one or more of these

conditions; access to improved water, access to improved sanitation facilities, sufficient living

area-not overcrowded, structural quality/durability of dwellings and security of tenure (World

Bank, 2015).

Maternal factors - education, knowledge on breastfeeding, morbidity and breast health. Socio-

economic factors - defined by income, occupation and proxy indicators such as ownership of

items.

Partial breastfeeding- an infant receives breast milk and any food or liquids including non-

human milk and formula (WHO, 2015).

Predominant breastfeeding – an infant receives breast milk (including milk expressed from a

wet nurse) as the predominant source of nourishment and allows water and water-based drinks,

fruit juice, ritual fluids, oral rehydration salts, drops or syrups (vitamins, minerals and medicine)

(WHO, 2015).

Pre-lacteal foods – non-breast milk feeds given before breastfeeding is initiated (WHO, 2015).

Post –lacteal feeds- non-breast milk fluids and foods given after breastfeeding has been initiated

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 CHAPTER TWO

REVIEW OF RELATED LITERATURE

Available research evidences related to demographic determinants of exclusive and non

exclusive breastfeeding among nursing mothers are reviewed in this chapter under the following

titles:

Conceptual framework

Theoretical framework

Empirical framework

Summary of literature reviewed

2.1 Conceptual Framework

2.1.1 Concept of Breast and Production of Breast Milk

Breasts are mammary secreting glands composed mainly of glandular tissue, which is arranged

in lobes, approximately 20 in number. Each lobe is divided into lobules that consist of alveoli

and ducts. The aveoli contain acini cells, which produce milk and are surrounded by

myoepithelial cells, which contract and propel the milk out. Small lactiferous ducts, carrying

milk from the alveoli, unite to form larger ducts. Several large ducts (lactiferous tubules)

conveying milk from one or more lobe emerge on the surface of the nipple. The lactiferous

tubules are distensible. Myoepithelial cells are oriented longitudinally along the ducts and, under

the influence of oxytocin, these smooth muscle cells contract and the tubule becomes shorter and

wider (Vorherr, 1974; Woolridge, 1986). As the tubule distends during active milk flow, it may

provide a temporary reservoir for milk (while the myoepithelial cells are maintained in a state of

contraction by circulating oxytocin). This is often shown diagrammatically and described as

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lactiferous sinuses (or ampullae). These researchers (Fraser & Cooper, 2013), further explained

that the nipple is composed of erectile tissue which is covered with epithelium cells and contains

plain muscle fibres, which have a sphincter - like action (milk ejection reflexes or let down) in

controlling the flow of milk. Surrounding the nipple is an area of pigmented skin called the

areola, which contains Montgomery's glands. These produce a substance which acts as a

lubricant during pregnancy and throughout breastfeeding (Fraser & Cooper, 2013).

Breast, nipple and areola vary considerably in size from one woman to another. The breast is

supplied with blood from the internal and external mammary arteries and branches from the

inter-costal arteries. The veins are arranged in a circular fashion around the nipple. Lymph drains

freely between the two breasts and into lymph nodes in the axillae and the mediastinum. During

pregnancy, oestrogen and progesterone (“mothering hormones” responsible for milk ejection

reflexes (MER)) induce alveolar and ductal growth as well as stimulating the secretion of

colostrums. Although colostrums is present from the 16 week of pregnancy, the production of

milk is held in abeyance until after delivery, when the levels of placental hormones fall. This

allows the already high levels of prolactin (hormone responsible for suckling and milk removal)

to initiate milk production. Continued production of prolactin is caused by the baby feeding at

the breast with concentrations highest during night feeds. Prolactin seems to be much more

important to the initiation of lactation than to its continuation. As lactation progresses, the

prolactin response to suckling diminishes and milk removal becomes the driving force behind

milk production (Applebaum, 1970). This protein accumulates in the breast as the milk

accumulates and it exerts negative feedback control on the continued production of milk.

Removal of this autocrine inhibitory factor (sometimes referred to as FIL - feedback inhibitor of

lactation) by removing the milk allows milk production to be stepped up again. It is because this

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mechanism acts locally (i.e within the breast) that each breast can function independently of the

other.

Milk release is under neuroendocrine control. According to Wong et al (2002), the nipple is

stimulated by the suckling infant and the posterior pituitary is prompted by the hypothalamus to

produce oxytocin. This oxytocin is the hormone responsible for the milk ejection reflex (MER),

or let - down reflex. This milk ejection reflex can be triggered by thoughts, sights, sounds, or

odours that the mother associates with her baby such as hearing the baby cry.

Wong, et al, (2002), further explained that oxytocin is the same hormone that stimulates uterine

contractions during labour. It contracts the mother's uterus after birth to control postpartum

bleeding and to promote uterine involution. Thus, mothers who breastfeed are at decreased risk

for postpartum hemorrhage. These uterine contractions that occur with breastfeeding can be

painful during and after the feeding, particularly in multiparas (more than one baby), for 3 to 5

days after giving birth. Prolactin and oxytocin have been referred to as the "mothering

hormones" since they are known to affect the postpartum woman's emotions as well as her

physical state. Many women have reported feeling thirsty or very relaxed during breastfeeding,

which may be due to these hormones (Wong, et al; 2002).

2.1.2 Exclusive Breastfeeding

In an effort to promote breastfeeding, the 54th World Health Assembly which met in Geneva,

May, 2001 affirmed the importance of exclusive breastfeeding for 6 months. The new resolution

(Ref: Agenda item 13:1, infant and young child nutrition, A) 54/45 in Paragraph 2(4) urged

member states to (Baby Milk Action, 2001): support exclusive breast feeding for six months as a

global public health recommendation taking into account the findings of the WHO Expert

Technical Consultation on optimal breast feeding and to provide safe and appropriate

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complementary foods, with continued breast feeding for up to two years or beyond (Fraser, et al;

2013). Since then researches have therefore shown that EBF for up to six months is associated

with increased weight and length gains.

The WHO/UNICEF (2014), defines exclusive breastfeeding as an infant’s consumption of

human milk with no supplementation of any type (no water, no juice, no non-human milk, and

no foods) except for drops or syrups consisting of vitamins, minerals, and medications (nothing

else) for six months and thereafter up to 24 months with timely introduction of other

supplements to support the infant’s growth and development. According to Ekele & Hamidu

(1997), EBF means no other drink or food is given to the infant, and the infant is fed exclusively

on breast milk from birth to 4-6 months of age. This is also one of the cardinal components of

the Baby Friendly Hospital Initiative (BFHI) which is aimed at protecting, promoting and

supporting breast feeding for optimal maternal and child health. It has been shown for some time

that exclusively breast fed babies who consume enough breast milk to satisfy their energy needs

will easily meet their fluid requirements even in hot dry climates (Ashraf, et al; 1998, Sachder,

et al; 2000).

In an effort to increase global breastfeeding rates, the WHO and UNICEF launched the Baby

Friendly Hospital Initiative (BFHI) in 1991. This initiative is comprised of ten steps to

successful breastfeeding with the aim of providing a health care environment for infants where

breastfeeding is the norm (Martens, et al; 2000). Maternity care facilities must implement each

of the ten steps to earn the designation of “baby-friendly” hospital. Some of the steps of the

BFHI include: “train all health care staff in skills necessary to implement the baby friendly

policy; help mothers initiate breastfeeding within 30 minutes of delivery; give newborn infants

no food or drink other than breast milk, unless medically indicated; practice rooming-in by

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allowing mothers and infants to remain together 24-hours-a-day; have a written breastfeeding

policy that is routinely communicated to all health care staff; inform all pregnant women about

the benefits and management of breastfeeding; show mothers how to breastfeed and how to

maintain lactation even if they should be separated from their infants; encourage breastfeeding

on demand; give no artificial teats or dummies to breastfeeding infants; foster the establishment

of breastfeeding support groups and refer mothers to them on discharge from hospital or clinic’’,

(DiGirolamo, 2001; Fraser et al, 2013). Studies have reported that, as of October 2000, only 27

hospitals had actually completed the process of becoming designated as baby friendly

(DiGirolamo, 2001). In order to assess the effects of the BFHI on breastfeeding rates and infant

growth, 17 infants were followed for 12 months, and their weights and heights were measured at

1, 2, 3, 6, 9, and 12 months. Infants in the experimental group weighed more than the control

group at one and three months, and a similar trend was observed for gain in length.

Infants exclusively breastfed for six months crawled and walked sooner, compared to infants

who were exclusively breastfed for only four months. Similar results were reported in another

study conducted to explore the relationship between breastfeeding and growth. One hundred and

eighty-five children were followed from birth to 20 months. Exclusively or predominantly

breastfed infants, for at least four months, had significantly (P=0.04) larger ponderal index

increments compared to children who were not. Among infants in a lower socioeconomic status

(SES) group, those who were fully breastfed for at least four months had larger length

increments (0.59 cm) compared to children who were not. However, these differences in

ponderal index and length were not significant in infants between six and 20 months of age.

Investigators concluded that EBF may have more benefits to the infant, particularly during the

early months of infancy (Eckhardt, et al; 2001). In another study by Onyango, et al; (1999),

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continued breastfeeding during the second year of life was positively associated with growth in a

cohort of 264 children, but it was also seen that linear growth of these children was hindered by

poor sanitation. A study showed that prolonged breastfeeding (>24months) was positively

associated with linear growth during the second and third year of life in 443 African toddlers

(Simondon et al., 2001). Several observational studies have also found that breast milk keeps the

infant adequately hydrated, even in tropical settings, such that additional fluids, including water,

tea, and other liquids are not required by the infant when breastfed (Black and Victora, 2002).

In addition to physiological benefits, a number of studies have shown that breastfeeding is

associated with positive effects on neurodevelopment. These advantageous effects have been

attributed to the presence of long chain polyunsaturated fatty acids in human milk. The fatty

acids, ecosapentaenoic acid (EPA) and docosahexaenoic acid (DHA), present in human milk

may be responsible for advanced neurodevelopment (ADA Reports, 2001). Higher erythrocyte

DHA concentration and better visual function was observed in full term breastfed infants

compared to formula-fed infants (Heinig & Dewey, 1996).

A. Benefits of Exclusive Breastfeeding

In a scientific research such as the studies conducted by the US Agency for Healthcare Research

and Quality (AHRQ), (2014) and WHO, (2014) revealed quite a number of benefits to exclusive

breastfeeding for both the infant and the mother asfollows:

 Greater immune health

During breastfeeding, antibodies pass to the baby. This is one of the most important features of

colostrums (the breast milk created for newborns). Breast milk contains several anti-infective

factors such as bile salt stimulated lipase (protecting against amoebic infections, lactoferrin

(which binds to iron and inhibits the growth of intestinal bacteria and immunoglobulin A (IgA)

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protecting against microorganisms (AHRQ, 2014; WHO, 2014) breast milk also enhances

maturation of the gastro intestinal (GI) tract and contains immune factors that contribute to a

lower incidence of diarrheal illness, and celiac diseases (Barnad, 1997; Lopez-Alarcon,

Villapando, and Fajardo, 1997; Scariah; Grummer-Strawn, and Fein, 1997).

 Lesser infections

Breastfed infants receive specific antibodies and cell-mediated immunologic factors that help

protect against Otitis media, respiratory illness such as respiratory syncytial virus and

pneumonia, urinary tract infections, bacteria and bacterial meningitis (Cushing, et al; 1998;

Lopez, 1997). Among other studies showing that breast fed infants have a lower risk of infection

than non-breastfed infants are:

a. In 1993 university of Texas Medical Branch Study, a longer period of breastfeeding was

associated with a shorter duration of some middle ear infections (Otitis media) in the first

two years of life.

b. In 1995 study of 87 infants found that breastfed babies had half the incidence of diarrheal

illness, 19% fewer cases of any otitis media infection, and 80% fewer prolonged cases of

otitis media than formula fed babies in the first twelve months of life.

c. Breastfeeding appear to reduce symptoms of upper respiratory tract infections in premature

infants up to seven months after release from hospital in 2002 study of 39 infants.

d. In 2014 case-control study found that breastfeeding reduced the risk of acquiring urinary

tract infections in infants up to seven months of age, with the protection strongest

immediately after birth.

e. Breastfeeding reduces the risk of acute otitis media, non-specific gastro enteritis, and severe

lower respiratory tract infections.

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 Reduced sudden infant death syndrome

Breastfed infants are less likely to die from sudden infant death syndrome (SIDS) (Ford &

Kelsey, 1993). Breastfed babies have better arousal from sleep at 2-3 months. This coincides

with the peak incidence of sudden infant death syndrome. A study conducted at the university of

Munster found that breastfeeding halved the risk of sudden infant death syndrome in children up

to the age of two.

 Less diabetes

Infants exclusively breastfed have less chance of developing diabetes mellitus type 1 than peers

with a shorter duration of breastfeeding and an earlier exposure to cow milk and solid foods.

Breastfeeding also appears to protect against diabetes mellitus type 2, at least in part due to its

effects on the child’s weight (AHRQ, 2014; WHO, 2014). Ricci (2014) stated that breastfeeding

exclusively is associated with avoidance of type 2 diabetes and heart disease. Breastfeeding may

also have a protective effect against childhood lymphoma and insulin-dependent diabetes (Davis,

1998; Gerstein, 1994).

 Less child obesity

Breastfeeding appears to reduce the risk of extreme obesity in children aged 39 to 42 months.

The protective effect of breastfeeding against obesity is consistent, though small, across many

studies and appears to increase with the duration of breastfeeding (AHRQ, 2014; WHO, 2014).

According to a report of American Academy of Pediatrics (AAP) (2016a, 2016b) exclusive

breastfeeding is less likely to result in overfeeding, leading to obesity. A study has also shown

that infants who are bottle fed in early infancy are more likely to empty the bottle or cup in late

infancy than those who are breastfed. Bottle feeding, regardless of the type of milk is distinct

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from feeding at the breast in its effect on infants self-regulation of milk intake. According to the

study, this may be due to one of three possible factors, including that when bottle feeding,

parents may encourage an infant to finish the contents of the bottle whereas when breastfeeding,

an infant naturally develops self-regulation of milk intake. A study in today’s pediatrics

associates solid foods given too early to formula-fed babies before 4 months old will make them

6 times as likely to become obese by age three. It does not happen if the babies were given solid

foods with breastfeeding (AHRQ, 2014; WHO, 2014).

 Less tendency to develop allergic disease (atopy)

There is a lower incidence of allergy among breastfed infants from families at high risk. Allergic

manifestations occur at a greater rate and are more severe in formula fed infants (Halken and

Host, 1996). In children who are at risk for developing allergic diseases (defined as at least one

parent or sibling having atopy), atopic syndrome can be prevented or delayed through exclusive

breastfeeding for four months, though these benefits may not be present after four months of

age. However, the key factor may be the age which non-breast milk is introduced rather than

duration of breastfeeding. Atopic dermatitis, the most common form of eczema can be reduced

through exclusive breastfeeding beyond 12 weeks in individuals with a family history of atopy,

but when breastfeeding beyond 12 weeks is combined with other foods incidents of eczema rise

irrespective of family history.

 Less necrotizing enterocolitis in premature infants

Necrotizing enterocolitis (NEC) is an acute inflammatory disease in the intestines of infants.

Necrosis or death of intestinal tissue may follow. It is mainly found in premature births. In one

study of 926 preterm infants, NEC developed in 51 infants (55%). The death rate from

necrotizing enterocolitis was 26% NEC was found to be six to ten times more common in infants

19
fed formula exclusively, and three times more common in infants fed a mixture of breast milk

and formula, compared with exclusive breastfeeding. In infants born at more than 30 weeks,

NEC was twenty times more common in infants exclusively on formula. A 2014 meta-analysis

of four randomized controlled trials found a marginally statistically significant association

between breastfeeding and a reduction in the risk of NEC.

 Other long term health effects

Breastfeeding may decrease the risk of cardiovascular disease in later life, as indicated by lower

cholesterol and C-reactive protein levels in adult women who has been breastfed as infants.

Although a 2001 study suggested that adults who had been breastfed as infants had lower arterial

dispensability than adults who had not been breastfed as infants, the report concluded that

breastfed infants “experienced lower mean blood pressure” later in life. It further stated that

there is an association between a history of breastfeeding during infancy and a small reduction in

adult blood pressure, but the clinical or public health implication of this finding is unclear. A

2016 study found that breastfed babies are better able to cope with stress later in life (AHRQ,

2014, WHO, 2014).

 Intelligence

Studies have examined whether breastfeeding in infants is associated with higher intelligence

later in life. Possible association between breastfeeding and intelligence is not clear. The 2014

review for the AHRQ found no relationship between breastfeeding in term infants and cognitive

performance. However, the 2014 review for the WHO suggests that breastfeeding is associated

with increased cognitive development in childhood. The review also states that the issue remains

of whether the association is related to the properties of breast milk itself, or whether

breastfeeding enhances the bonding between mothers and thus contributes to intellectual

20
development.

Breastfeeding is a cost effective way of feeding an infant, providing nourishment for the infant at

a less cost to the mother. Frequent and exclusive breastfeeding can delay the return of fertility

through lactational amenorrhea, though breastfeeding is an imperfect means of birth control

(AHRQ, 2014).

 Bonding

Breastfeeding provides a unique bonding experience and increase maternal role attainment

(Lawrence, 1999). During breastfeeding, hormones are released to help strengthen the maternal

bond. Support for a mother while breastfeeding can assist in familiar bonds and help build a

paternal bond between father and child.

 Hormone release

Breastfeeding releases oxytocin and prolactin hormones that relax the mother and make her feel

more nurturing toward her baby. Breastfeeding soon after giving birth increases the mother’s

oxytocin levels, making her uterus contract more quickly and reducing bleeding. (AHRQ, 2014;

WHO, 2014). Breastfeeding also decreases risk of postpartum hemorrhage (Lawrence 1999;

Ricci, 2014).

 Weight loss

Mothers who are breastfeeding tend to return to the pre-pregnancy weight more quickly (Dewey,

Heining & Nommsen, 1993). As the fat accumulated during pregnancy, is used to produce milk,

extend breastfeeding for at least 6 months can help mothers’ lose their weight. However, weight

loss is highly variable among lactating women; monitoring the diet and increasing the

amount/intensity of exercise are more reliable ways of losing weight. The 2014 review for the

AHRQ found the effect of breastfeeding in mothers on returning to pre- pregnancy weight was

21
negligible, and the effect of breastfeeding on postpartum weight loss was unclear”.

 Natural postpartum infertility

Breastfeeding may delay the return to fertility for some women by suppressing ovulation. A

breastfeeding woman may not ovulate or have regular periods, during the entire lactation period.

Though the period in which ovulation is absent differs in each woman. This lactation

amenorrhea has been used as an imperfect form of natural contraception with greater than 98%

effectiveness during the first six month after birth if specific nursing behaviours are followed. It

is possible for women to ovulate within two months after birth while fully breastfeeding and get

pregnant again (AHRQ & WHO, 2014). According to Pryor & Huggins (2014), breastfeeding

can afford some protection against conception, although it is not a reliable contraception method.

 Other long term heath effects

Women who have breastfed have a decrease risk of ovarian, uterine and breast cancer (Enger

1998; Rosenblett & Thomas, 1995). A 2014 study indicated that lactation for at least 24 months

is associated with 23% lower risk of coronary heart diseases (AHRQ & WHO, 2014). Although

the review found no relationship between history of lactation and the risk of osteoporosis,

mothers who breastfeed longer than eight months benefit from bone re- mineralization. Also

breastfeeding diabetic mothers require less insulin. According to Malmo University study

published in 2011, women who breastfed for a longer duration have a lower risk for contracting

rheumatoid arthritis than women who breastfed for a shorter duration or who had never

breastfed.

2.1.3 Non-Exclusive Breastfeeding

Commercial formulas are produced to replace or supplement breast milk. Formulas are

sometimes called “breast milk substitutes” or „artificial breast milk’ because manufacturers must

22
adapt them to correspond to the components in breast milk as much as possible. According to

Fraser et al (2013), it is an offence under law to sell any infant formula as being suitable for the

newborn unless it meets the compositional and other criteria set out in the infant formula and

follow-on formula regulations.

The researchers, further stress that despite the claims made by formula manufacturers, there is no

obvious scientific basis on which to recommend one brand over another. There is no necessity

for the mother to stick to one brand, especially if she finds that one brand seems to disagree with

her baby, she should try switching brands.

This has been made easier by the availability of ready-to-feed sachets and cartons, as with these,

mothers can experiment without having to buy large quantities. Babies with underlying

metabolic disorders, such as galactasoemia or phenylketonia will need the appropriate prescribed

breast milk substitute. Nevertheless, though artificial milk may be highly processed, factory

produced product, inevitably there will from time to time be inadvertent errors. Recorded errors

in the past include too much or too little of an ingredient, accidental contamination, incorrect

labeling and foreign bodies (Fraser, et al, 2013).

Therefore, according to Bobak, et al (1989), mothers should be advised to inspect the contents of

the tin or packet before using it and if it looks or smells strange, return it to the place it was

purchased. Nevertheless, physicians who recommend formula’s for infant feeding should

provide written instructions as to the amount of formula to be fed the infant over 24 hours and

when to increase the amount to ensure meeting the growing infant nutrition needs.

Ricci (2011), however, opined that formula feeding requires more than just opening, pouring,

and feeding. Parents need information about the types of formula available, preparation and

storage of formula, equipment, feeding positions and the amount to feed their new born. The

23
mother also needs to know how to prevent lactation.

Non-exclusive breastfeeding therefore means breast milk along with infant formula, baby food

and even water, depending on the age of the child. The decision to feed a baby infant formula

may be the result of the mother’s or partner’s personal preference, the influence of other

significant factors such as maternal age, mother’s level of education, employment, income level,

family members, or simply a lack of familiarity with breast feeding.

Occasionally, there is no other option, the mother may have extensive breast scarring or may

have a bilateral mastectomy; the mother may be taking medications that prelude breastfeeding;

or the baby may be adopted (some mothers are able to include lactation for an adopted baby).

Rarely an infant may have galactosemia and must be fed lactose-free formula (Wong, et al;

2002). According to McKinney, et al; (2011), some women are simply embarrassed by

breastfeeding, seeing the breasts only in a sexual context. Many mothers have little experience

with family or friends who have breast fed infants.

The decline in the practice of breastfeeding, such as in developed countries like the U.S., has

been observed in developing countries as well including Nigeria (Galler et al., 1998). Sub-

optimal breastfeeding practices still prevail in many countries, especially in rural communities.

A study that examined infant feeding practices in 12 rural communities revealed that delayed

initiation of breastfeeding, prelacteal feeding, and failure to practice EBF were widespread.

Moreover, colostrums was considered “hot milk” causing diarrhea and stomach pain, and thus

was not given to infants (Semega-Janneh, et al; 2001). In a study conducted with 136 women, it

was observed that stress during labour and delivery was associated with delayed onset of

lactation (Grajeda & Perez-Escamilla, 2002).

24
A. Benefits of Non-Exclusive Breastfeeding

Breastfeeding is considered the best nutritional option for babies by the major medical

organizations, but it is not right for every mother. Commercially prepared infant formulas are a

nutritious alternative to breast milk, and even contain some vitamins and nutrients that breastfed

babies, need to get from supplements. Manufacturers under sterile conditions, commercial

formulas attempt to duplicate mother’s milk using a complex combination of proteins, sugars, fat

and vitamins that would be virtually impossible to create at home. So if you do not breastfeed

your baby, it is important that you see only a commercially prepared formula and that you do not

try to create your own (Hirsh, 2015c). In addition to medical concerns that may prevent

breastfeeding, for some women, breastfeeding may be too difficult, stressful or demanding. In a

review by Hirsh (2015) found the following benefits of formula feeding.

Convenience: Either parents (or another Caregiver) can feed the baby a bottle at anytime

(although this is true for women who pump their breast milk). This allows the mother to feel

more involved in the crucial feeding process and the bonding that often comes with it.

Flexibility: Once the bottles are made a formula feeding mother can leave her baby with a

partner or caregiver and know that her little ones’ feedings are taken care of. There is no need to

pump or to schedule work or other obligations and activities around the baby’s feeding schedule.

And formula feeding mothers do not need to find a private place to nurse in public. However, if

mother is out and about with baby, she will need to bring supplies for making bottles.

Time and frequency of feeding: Because formula digests slower than breast milk, formula fed

babies usually need to eat less often than do breastfed babies.

Diet: Women who opt for formula feed do not have to worry about the things they eat or drink

that could affect their babies.

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B. Challenges of Non-Exclusive Breastfeeding

As with breastfeeding, there are some challenges to consider when deciding whether to formula

feed.

Organization and preparation: Enough formula must be on hand at all times and bottles must

be prepared. The powdered and condensed formulas must be prepared with sterile water (which

needs to be boiled until the baby is at least 6 months old). Ready to feed formulas that can be

poured directly into a bottle without any mixing of water tend to be expensive. Bottles and

nipples need to be sterilized before the first use and then washed after every use (this is also true

for the breast feeding women who give their babies bottles of pumped breast milk). Bottles and

nipples can transmit bacteria if they are not cleaned properly. Bottles left out of the refrigerator

longer than 1 hour and any formula that a baby does not finish must be thrown out. And

prepared bottles of formula should be stored in the refrigerator for longer than 24 to 48 hours

(check the formula label for complete information). Some parents warm bottles up before

feeding the baby, although this often is not necessary.

Lack of antibodies: None of the important antibodies found in breast milk are found in

manufactured formula, which means that formula does not provide the baby with the added

protection against infection and illness that breast milk does (Hirsh, 2015).

Expense: formula can be costly. Powdered formula is the least expensive, followed by

concentrated, with ready-to-feed being the most expensive and specially formulas (i.e. soy and

hypoallergic) cost more, sometimes far more than the basic formulas (Hirsch, 2015).

Possibility of producing gas constipation: Formula fed babies may have more gas and firmer

bowel movements than breastfed babies (Hirsch, 2015).

Cannot match the complexity of breast milk: Manufactured formulas have yet to duplicate the

26
complexity of breast milk, which changes as the baby’s needs changes (Hirsch, 2015).

2.1.4 Demographic Determinants of Exclusive and Non-Exclusive Breastfeeding

Studies have been conducted to identify variables that influence infant feeding decisions. Many

demographic factors such as maternal age, education, employment, socioeconomic and cultural

factors, have been shown to influence women’s decision to either exclusively or non-exclusively

breastfeed their infants (Bass & Groer, 1997; Goksen, 2002; Scott & Binns, 1999).

2.1.5 Breastfeeding and Mother’s Age

Age is an important demographic variable and the primary basis of demographic classification.

The age structure of the practice of exclusive and non exclusive breastfeeding is however not

found in the earlier conducted Nigeria Demographic and Health Survey (NDHS’). However,

other studies have found significant influence of age in the practice of exclusive and non

exclusive breastfeeding.

Research have shown that women who are older (>25 years) are more likely to initiate and

continue breastfeeding compared to younger women (Dennis, 2002b; Ertem, et al; 2001; Scott &

Binns, 1999; Wagner & Wagner, 1999). Research published between 1980 and 1999 indicated

that only 9.1% of mothers younger than 20 years of age continued to breastfeed to six months,

whereas women who were older were more likely (15-34%) to have breastfed for six months. A

feeling of embarrassment and regard for breastfeeding as a private behaviour has been associated

with maternal age (Wambach & Cole, 2000). Adolescent girls who had positive attitudes toward

and more knowledge about breastfeeding were more likely to consider breastfeeding (Losch, et

al; 1995; Wambach & Cole, 2000). Mothers who were young, single, from low income and

ethnic minority groups, and who had negative attitudes toward breastfeeding were reported as

the least likely to breastfeed (Dennis, 2002b; Wagner & Wagner, 1999). A study was conducted

27
in 1995 with teenage mothers in the Michigan WIC program. Breastfeeding initiation rate and

predictors of breastfeeding initiation in these teenage mothers were evaluated. Data from the

1995 Pregnancy Nutrition Surveillance System were used for this study, and a total of 3,534

teenagers between the ages of 12 and 19 years were included. Only 35.1% of mothers initiated

breastfeeding (Park, et al; 2013). There was a significant difference (P<0.001) in the prevalence

of breastfeeding between white (40.4%) and black (19.5%) teenage mothers. Further analyses

revealed that level of education, marital status, anemia status, and smoking during pregnancy

influenced the initiation rate among white teenage mothers, whereas household size, parity and

level of education influenced the initiation rate among black teenage mothers. Black teenage

mothers were 2.38 times less likely to initiate breastfeeding compared to white teenage mothers.

The authors concluded that all teenage mothers were less likely to initiate breastfeeding.

Moreover, women with these characteristics should be targeted for breastfeeding support and

education (Park, et al; 2013).

A survey of 100 teenage females in sub-urban showed that although 79% of them intended to

have children, only 52% planned to breastfeed. Embarrassment and increased fatigue were

perceived as barriers to breastfeeding among these teenage girls (Leffler, 2000). These teenagers

were also not certain whether breastfeeding was beneficial to the nursing mother. The authors

concluded that teenage girls should be targeted for breastfeeding education (Leffler, 2000). A

similar but separate study was conducted to evaluate adolescents’ attitudes and subjective norms

toward breastfeeding. In this study, 203 males and 236 females from high schools were

surveyed. Although adolescents had positive attitudes regarding the advantages of breastfeeding,

they had negative subjective norms about breastfeeding, especially among males.

Fewer males versus females had seen a mother breastfeeding her infant (P=0.001), and overall,

28
males had more incorrect beliefs about breastfeeding compared to females. Compared to

females, males more strongly believed that supply of breast milk was related to breast size

(P=0.004), people compared the breastfeeding mother to a cow (P=0.0001), breastfed infants

were less “self- sufficient” later in life (P=0.0002), and that when breastfeeding, a mother

exposes her breasts to the public (P=0.0002). The authors concluded that because subjective

norms for fathers are important determinants of breastfeeding, education of adolescent males

about breastfeeding is also necessary (Goulet, et al; 2013).

A study conducted was designed to examine the effect of a breastfeeding campaign for

adolescent females on scores of attitudes, norms, and intentions regarding breastfeeding. The

intervention group included 207 adolescent females exposed to the breastfeeding campaign

compared to a control group (n=205). The mean score for intention to breastfeed was

significantly higher (P<0.05) in the intervention group (4.07) compared to the control group

(2.55). Females exposed to the campaign had more positive attitudes, subjective norms and

intentions toward breastfeeding than the control group (Kim, 1998). These investigators

concluded that educating adolescents about breastfeeding was effective and positively promoted

breastfeeding (Kim, 1998). Results of a study that assessed students’ attitudes toward

breastfeeding revealed that although respondents had generally positive attitudes about

breastfeeding, a significant number of college students considered breastfeeding to be

unattractive for a woman (Forrester, et al; 1997). Of 346 high school and 244 college students,

only 135 individuals acknowledged having been breastfed.

Embarrassment was perceived as a major barrier to breastfeeding, and breastfeeding in public

was not considered acceptable by many of the students (Forrester, et al; 1997). A study

conducted to assess attitudes toward breastfeeding in the north-central region involving students,

29
faculty, and staff showed that although students perceived breastfeeding as healthy, they

considered bottle-feeding more convenient and less embarrassing than breastfeeding. Although

all participants (n=107) agreed that breastfeeding is better than bottle-feeding, they believed that

breastfeeding is a private affair and should not be done in public (O’Keefe, et al; 1998). Thus,

age has an important impact on intent to breastfeed.

Mundi (2015), found positive influence of maternal age in the practice of exclusive

breastfeeding, which shows that the practice of exclusive breastfeeding is highest among

mothers between the ages of 20-24 (84.4%), compared with mothers in other categories. In fact

only 25% of mothers above 45 years have practice exclusive breastfeeding. This may be because

women within this age bracket are more full time housewife and may have more time to

breastfeed. According to McKinney, et al; (2011), women who are most likely to breastfeed are

Asian or White, ages 25 to 34 years. This is because they have a college education and live in

the mountain or pacific regions of the United States and receive special supplemental nutrition

programmme for Women, Infants and Children (WIC) benefits. The study further revealed that

African-American still have the lowest rates of breastfeeding than other groups in recent years.

A study by Ekele & Hamidu (1997), observed that majority of mothers who practice exclusive

breastfeeding were between 20-29 years. Out of the 120 respondents sampled in the practice of

exclusive breastfeeding, 17.5% were between 18 - 24 years of age, 42.5% fall between 25-31

years, 23.4% were 32-38 years, while those aged 39- 45 years had 13.3%. 45 years and above

had 3.3%. By implication, exclusive breastfeeding was highest among women between 25 to

31years of age. The researchers concluded that older mothers were more likely to exclusively

breastfeed than the younger ones. Exclusive breastfeeding was significantly associated with

maternal age in an assessment of breastfeeding practices of 228 nursing mothers. Most mothers

30
that practice exclusive breastfeeding, 190 (83.3%) were aged between 20 and 34 years (Ukegbu,

et al, 2011). A prospective cohort study of 240 nursing mothers carried out in three

comprehensive health centers of Nnamdi Azikwe University Teaching Hospital (NAUTH) found

that EBF was significantly associated with maternal age (p<0.05).

Focus group discussion showed that mothers believed that adequate nutrition and physical

strength, financial and emotional support to them would increase EBF practice. A 26 year old

participant in one of the focus group discussion (FGD) sessions said that “while waiting for the

breast milk to flow, it is good to give baby water or glucose water, after all water is the life of a

fish, it is good to give water so as to sustain the baby before breast milk starts to flow”. Although

all the participants in the FGDs agreed that colostrums was good for the baby. A 29 year old

mother in the FGD said that “colostrums is good because it helps the child to know the taste of

breast milk and will make the baby to always demand for it”. Exclusive breastfeeding was

therefore practiced more frequently by mothers aged 35-39 years compared with those less than

20 years old (x2=9.89, p=0.0042). Oche, Umar and Ahmed (2011), found that a total of 84

(47%) of the respondents’ were between the ages of 23-32 years, while only29 (16%) were

above 38 years of age with a mean age of 29.8+10.3years. According to them age was found not

to have influenced the practice of exclusive breastfeeding. They concluded that young mothers

below the age of 20 were more likely to non-exclusively breastfeed their infants. Similarly,

Ogunlesi, (2010), opined that maternal age does not confer any advantage on breastfeeding

practices.

2.1.6 Breastfeeding and Mother’s Level of Education

Female education has severally been described as one of the strongest determinants of the

practice of exclusive breastfeeding. Many studies have found significant influence on the

31
practice of exclusive and non-exclusive breastfeeding.

According to Shealy, Li, Benton & Grummer (2016), mothers who are college graduates were

more likely to breastfeed their infants than are mothers with lower levels of educational

attainment. For infants born in 2014, 60% of mothers with a college education breastfed their

infant at six months, compared with 41% with some college education, 31% with a high school

degree, and 37% with less than a high school degree. Mothers with some college were more

likely to ever breastfeed than were women with lower levels of education, and mothers who

were college graduates were the most likely to breastfeed: 67 and 66% of women with no high

school diploma, or a high school diploma only, respectively, ever breastfed, compared with 77%

of women with some college, and 88% of women with at least a bachelor’s degree.

At twelve months, women with a high school diploma only were the least likely (15%) to still be

breastfeeding, followed by women without a high school diploma, and those with some college,

at 22 and 21%, respectively. College graduates were also the most likely to breastfeed at twelve

months, at 31%. A sample of 758 mothers were drawn for study to determine the reasons behind

cessation of breastfeeding during the first year postpartum. Analysis of these data showed that

women who were older, with higher education and more children, breastfed for longer duration.

During the early postpartum months, the mother encountered a greater number of problems with

breastfeeding, and many women chose to wean their infants before six months because they

thought that “the infant was old enough” or stated that the “infant weaned itself” (Kirkland and

Fein, 2013). The authors concluded that breastfeeding promotion programs should educate the

mothers that the infant is not too old to be breastfed at six months (Kirkland and Fein, 2013). In

an effort to determine if psychological and biomedical factors, independent of demographic

factors, influenced duration of breastfeeding during the first six postpartum months, researchers

32
conducted an observational and longitudinal study with 539 mothers.

At hospital discharge, 97% of mothers were exclusively breastfeeding their infants, but this rate

dropped to 83% at one month, 56% at four months, and 19% at six months.

Mothers with secondary school or college education exclusively breastfed for longer duration

than mothers with primary education (P<0.01). Mothers who breastfed their previous infants for

more than six months were 14 times more likely to exclusively breastfeed their current infants

for six months compared to women who breastfed their previous infants for less than one month

(Cernadas et al., 2013). The duration of breastfeeding and percentage of EBF at six months was

significantly (P<0.001) more in mothers with higher education than those with lower education.

Feelings of embarrassment have been shown to be a major hindrance to breastfeeding, (Perez-

Escamilla, et al; 1998).

Breastfeeding and Mother’s Occupation

Many studies have shown that one of the barriers to breastfeeding is work status. With increased

urbanization and industrialization, more and more women have joined the work force.

An estimated 50% of women employed in the workplace are of reproductive age and return to

work within one year of their infants’ births (Wyatt, 2002).

The Bureau of Labour Statistics reported that in 2002, 51% of women with children under 1 year

of age were employed outside the home (Libbus and Bullock, 2002), and according to the Ross

Mother’s Survey, only 22% of women employed full-time breastfed their infants compared to

35.4% of mothers who were not employed (Libbus & Bullock, 2002).

Researchers examined the 1988 National Maternal and Infant Health Survey (NMIHS) to

explore the association between employment factors associated with breastfeeding initiation and

duration. Of the 26,355 mothers sampled in the NMIHS, only 1,506 cases of employed breast-

33
feeding women were used. Results showed that maternal employment was not responsible for

low rates of breastfeeding initiation. However, it was observed that breastfeeding women who

returned to work weaned their infants earlier compared to breastfeeding women who did not

work. The negative association between employment and duration of breastfeeding was

strongest in developed countries, and duration of maternity leave was significantly (P<0.01)

associated with duration of breastfeeding (Visness & Kennedy, 1997).

Survey data from 10,530 women were analyzed to determine the association between

breastfeeding and employment. Results showed that 79% (n=8,316) of the women initiated

breastfeeding, and of the 4,837 mothers who planned to work postpartum, 83.5% of them

initiated breastfeeding compared to 75.2% of the 5,693 mothers who did not plan to work

postpartum (P=0.001). However, mothers who planned to return to work before six weeks

postpartum were significantly (P<0.05) less likely to initiate breastfeeding compared to mothers

who were not planning to return to work (Noble, 2001). Other studies have also shown a

competition between breastfeeding and work.

In general, if a mother decides to return to work within six weeks postpartum, she is less likely

to initiate breastfeeding (Meek, 2001; Roe, et al., 1999; Scott & Binns, 1999). Similar findings

were reported in studies conducted overseas. It was observed that women working outside the

home in Thailand were less likely to breastfeed after they resumed their work. At six months

postpartum, 80% of those women working at home were still breastfeeding, whereas less than

40% of those women employed outside of the home continued to breastfeed (Yimyam, et al;

1999). Some studies have shown that intention to return to paid employment is associated only

with breastfeeding duration but not with breastfeeding initiation (Dennis, 2002b; Meek, 2001;

Wright, 2001; Wright, et al; 1998). To determine the effect of part-time employment on

34
breastfeeding initiation and duration, researchers surveyed 2,615 mothers during the first month

postpartum and then during months 2, 3, 4, 5, 6, 7, 9, and 12. Data from 1,488 surveys were

analyzed and results showed that 76% of the mothers initiated breastfeeding. No differences in

initiation rates were found between mothers who expected to work part-time and those who did

not expect to return to work. However, mothers working full-time breastfed 8.6 weeks less than

nonworking mothers (P<0.05), and part-time work of more than four hours per day decreased

the duration of breastfeeding (Fein & Roe, 1998).

2.1.7 Stages of Breast Milk

Human milk is a highly complex species specific fluid uniquely designed to meet the needs of

the human infant. Human milk contains antibodies that provide some protection against a broad

spectrum of bacteria, viral and protozoan infections. According to Fraser, et al; (2013), the

human milk varies in its composition as follows:

With the time of day (for example, the fat and protein content is lowest in the morning and

highest in the afternoon). With the stage of the lactation (for example, the fat and protein content

of colostrums is higher than in mature milk). In response to maternal nutrition (for example,

although the total amount of fat is not influenced by diet, the type of fat that appears in the milk

will be influenced by what the mother eats). McKinney, et al; (2011), however, explained that

the composition of breast milk changes in three phases viz: colostrums, transitional milk, and

mature milk.

The major secretion of the breast during pregnancy and the first 7 to 10 days after giving birth is

colostrums. Colostrums is a thick, yellowish fluid and is more concentrated than the mature milk

(foremilk and hind milk) and is extremely rich in immunoglobulin’s, especially secretory IgA

(immunoglobulin A) which helps to protect the infant’s gastro intestinal tract from infection.

35
Concentration of protein and minerals, but less fat than mature milk, colostrums help establish

the normal flora in the intestines and its laxative effect speeds the passage of meconium

(McKinney, et al; 2011).

McKinney, et al; (2011), further states that transitional milk appears, as the milk changes from

colostrums to mature milk. Immunoglobulin’s and proteins decrease and lactose, fat and calories

increase. The vitamin content is approximately the same as that of mature milk.

After approximately 2 weeks of delivery, mature milk (foremilk and hind milk) replaces

transitional milk. Initially there is a release of bluish white foremilk that is part skim milk (about

60% of the volume) and part whole milk (about 35% of the volume). It provides primarily

lactose, protein and water-soluble vitamins. The hind milk or cream (about 5%) is usually let-

down to 20 minutes into the feeding, although it may occur sooner. It contains the denser

calories from fat necessary for optimal growth and contentment between feedings. Because of

this changing composition of human milk during each feeding, it is important to breast feed the

infant long enough to supply a balanced feeding. Milk production gradually increases, so that by

the time the infant is 2 weeks old, the mother produces 720 to 900ml of milk every 24 hours.

(Wong, et al; 2002).

The most dramatic change in the composition of milk usually occurs during the course of a feed.

At the beginning of the feed the baby receives a high volume of relatively low fat milk (this has

come to be known as the foremilk). As the feeding progresses, the volume of milk decreases but

the proportion of fat in the milk increases, sometimes to as much as five times the initial value

(Hall, 1999; Jackson, et al; 1987). This has come to be known as the hindmilk).

2.1.8 Importance of Breast Milk in the Growth and Development of Infant

Human milk is species specific having evolved overtime to optimize the growth and

36
development of the infant and young child. It has been classified by scientists and health workers

as the best natural food for babies. According to Mundi (2015), breast milk contains all the

necessary nutrients for the healthy growth of the child. The benefits are numerous ranging from

providing the infant with antibodies, helping ward off risks of illness and providing the baby

with all his nutritional needs.

Accordingly, WHO (2014), stated that breast milk provides all the energy and nutrients that the

infant needs for the first six months of life, and it provides about half or more of a child’s

nutritional needs during the second half of the first year up to one-third during the second year of

life. Furthermore, breast milk not only protects the infant against infectious and chronic diseases,

but also promotes sensory and cognitive development in addition to contributing to the health

and well-being of mothers, helping in birth spacing reducing the risks of ovarian and breast

cancers as well as increasing family and national resources.

The American Academy of Pediatrics (AAP) (2016a) and American Dietetic Association (ADA)

(2016) recommended that only breast milk be given for the first 6 months after birth.

Breastfeeding should continue until the infant is at least 12 months old with the addition of

solids beginning at 6 months of age. WHO and UNICEF (2016), further strengthened the

recommendation that infants be exclusively breastfed during the first six months of life and that

infants be given solid or semi-solid complementary foods in addition to continued breastfeeding

from age 6 months to 24 months or more when the baby is fully weaned.

Exclusive breastfeeding is recommended because breast milk is uncontaminated and contains all

the nutrients necessary for infants in the first few months of life. In addition, the mother’s

antibodies in breast milk provide immunity to disease. Early supplementation is discouraged for

several reasons. First, it exposes infants to risk of infection. Second, it decreases infant’s intake

37
of breast milk and therefore the frequency of breastfeeding, which reduces breast milk

production. Third, in low resource settings, supplementary food is often nutritionally inferior.

AAP (2014), further states that the breastfed infant is the reference or normative model against

which all alternative feeding methods must be measured with regard to growth, health,

development and all other short and long term outcomes.

Human milk is ideal for infant growth and development. The composition of breast milk changes

throughout the lactation period according to each infant’s requirement and has an appropriate

balance of nutrients that are easily digested and bioavailable (Dewey, 2000). Studies have shown

that breast milk has low concentrations of the amino acids, methionine, phenylalanine, and

tyrosine, and high levels of cystine and taurine. This composition of breast milk prevents central

nervous system damage in infants and aids in neurodevelopment (Picciano, 2001). According to

ADA (2016), breast milk not only provides energy but also contains enzymes such as lipoprotein

lipase, pancreatic lipase, and amylase, which aid in the digestion of nutrients. Breast milk also

provides fat and water-soluble vitamins, and minerals contained in breast milk are more bio

available compared to infant formula and are present in required quantities for the infant. On an

average, breast milk has been shown to provide 375 and 500 kcal/d at 6 and 11months

respectively (Dewey, 2000). While others consider complementary feeding of breastfed infants

necessary to promote optimal growth and development during the first few years of life, studies

have shown that EBF for six months provides adequate nutrition for normal growth of the infant

up to six months of age (Dewey, 2001b). The relatively low content of protein and sodium in

human milk places less load on the immature kidney of the infant (ADA Reports, 2001). With

respect to protein, human milk contains a high ratio of whey to casein, which is easily digestible.

Non-lactose carbohydrate has been shown to play a role in an infant’s ability to resist infections,

38
and fatty acids are essential for brain development. A number of studies have shown that

breastfed infants gain weight rapidly during the first 2-3 months of life, followed by a relatively

slower growth rate compared to formula-fed infants. Studies showed that breastfed infants self

regulate their energy requirement (Dewey, 2001a) by maintaining a lower body temperature and

metabolic rate than formula-fed infants (Dewey, 2001a; Eckhardt et al, 2001).

In a study of 430 breastfed infants, there was only one hospital admission due to respiratory

illness compared to 51 admissions in 346 bottle-fed infants; authors of this study concluded that

breastfeeding prevented hospitalizations for respiratory illnesses (Beaudry, etal; 1995).

Research showed that infants who were breastfed and given pre-lacteal feedings (colostrums)

had fewer episodes of diarrhea (Ziyane, 1999). Studies confirming the relationship between

breastfeeding and other childhood illnesses indicate that breastfeeding protects infants against

infectious diseases including bacteraemia, meningitis, infant botulism, and urinary tract

infections (Heinig & Dewey,1996). Breastfeeding has also been shown to protect against chronic

illnesses including insulin-dependent diabetes mellitus, Crohn’s disease, ulcerative colitis,

childhood cancers such as lymphoma (Heinig & Dewey, 1996), and sudden infant death

syndrome (Dennis,2002b). In a study conducted with 582 caregivers, it was observed that 45.9%

of the infants were breastfed for at least one year; further examination showed that a decrease in

breastfeeding was associated with increased episodes of diarrhea (McLennan, 2000).

2.1.9 Basic Nutritional needs of Infants

The full-term newborn needs approximately 100 to 110 Kcal (45 to 50 Kcal/kg) of body weight

each day. Breast and formulas used for the normal newborn contain 20 kcal (Blackburn, 2014;

Rosenberg, 2014). During the early days after birth, infants may lose up to 10% of their birth

weight because of normal loss of extracellular water and the consumption of fewer calories than

39
needed (Green, 2015). Newborns may fall asleep before feeding adequately and have a small

stomach capacity at birth. Capacity increases rapidly so that many infants take 60 to 90ml by the

end of the first week. Infants usually regain the lost weight by 2 weeks of age (Feigelman, 2014).

Infants should be evaluated for feeding problems if weight loss exceeds 7% to 8%, if loss

continues beyond 3 days of age, or if the birth weight is not regained by 2 weeks of age in the

full term infant, AAP and American College of Obstetricians and Gynecologist (ACOG), 2014;

Stellwagen & Bois, 2016).

The calories needed by the newborn are provided by carbohydrates, proteins and fat in breast

milk or formula. Full term neonates digest simple carbohydrates and proteins well. Fats are less

well digested because the lack of pancreatic lipase in the breast milk and formula (Mckinney et

al; 2011). Because newborns lose water easily from the skin, kidneys and intestines, they must

have adequate fluid intake each day. The normal newborn needs approximately 40 to 60ml/kg

(18 to 27ml/kg) a day by the end of the first week (DeMarini & Roth, 2014). Breast milk or

formula supplies the infants fluid needs. Additional water is unnecessary (Mckinney, et al;

2011).

Protein

The concentrations of amino acids in breast milk are suited to the infant's needs and ability to

metabolize them. Breast milk is high in taurine, which is important for bile conjugation and

brain development. Breast milk is low in tyrosine and phynlalanine, corresponding to the infant's

low levels of enzymes to digest them. The protein produced a low solute load for the infant’s

immature kidneys (Franklin & Figueroa, 2016). Casein (a by- product of butter manufactured)

and whey (a by-product of cheese manufactured) are the proteins in milk. Casein forms a large

insoluble curd that is harder to digest than the curd from whey, which is very soft. Breast milk is

40
easily digested because it has a high ratio of whey to casein. Commercial formulas must be

adapted to increase the amount of whey so that the curd is more digestible (Mckinney, el al;

2011). Many infants fed cow's milk-based formulas develop allergies to the protein in the milk.

Because breast milk is made for the human infant, it is unlikely to cause allergies. Infants with a

family history of allergies are less likely to develop them if they are breastfed (Lawrence &

Lawrence, 2016). Although breast milk does not cause allergies, allergenic foods the mother has

eaten may pass to her milk. If the infant reacts to the mother's diet, the offending food should be

identified and eliminated (Mckinney, et al; 2011).

Carbohydrate

Lactose is the major carbohydrate in breast milk. It improves absorption of calcium and provides

energy from brain growth. Other carbohydrates in breast milk increase intestinal acidity and

impede growth of pathogens (Rioden, 2016).

Fat

For infants to acquire adequate calories from the limited amount of human milk or formula they

are able to consume, at least 15% of the calories provided must come from fat (tryglycerides).

The fat must be easily digestible. Fat in human milk is easier to digest and absorb than that in

cow milk because of the arrangement of the fatty acids on the glycerol molecule and because of

the presence of the enzyme lipase (Wong, et al; 2002). The researchers, further stated that cow

milk is used in most infant formulas, but the milk fat is removed and replaced by another fat

source, such as corn oil that can be digested and absorbed by the infant. If whole milk or

evaporated milk without added carbohydrate is fed to infants, the resulting fecal loss of fat (and

therefore loss of energy) may be excessive because the milk moves through the infant's

intestines too quickly for adequate absorption to take place. This can lead to poor weight gain. In

41
addition to its energy contributions, fat also furnishes essential fatty acids (EFA) which are

required for growth and tissue maintenance. EFAs are components of cell membranes and

precursors of some hormones. Inadequate intake of EFAs results in eczema and growth failure.

The lack of EFAs in skin and low fat milk is another reason infants should not be fed these

products (Wong, et al; 2002).

Vitamins

Human milk contains all the vitamins required for infant nutrition, with individual variations

based on maternal diet and genetic differences vitamins are added to cow's milk formulas to

approximate the levels in breast milk. While cow's milk contains adequate amounts of vitamin A

and vitamin B complex, vitamin C (ascorbic acid) and vitamin E must be added (Wong, et al;

2002). Vitamin A, E and C are high in breast milk. The vitamin D content of breast milk is low,

and supplementation is recommended by 2 weeks of age (APP, 2016a; Kleinman, 2014).

According to Wong, et al; (2002), human milk may be somewhat deficient in vitamin D,

supplementation may not be necessary, provided that the infant is exposed to sunlight for 30

minutes per week wearing only a diaper or for 2 hours per week fully clothed but without a hat.

To prevent rickets, supplementation may be recommended for preterm infants and for dark-

skinned infants whose mothers eat vegetarian diets that exclude meat, fish and dairy products.

Vitamin K is also essential, for the synthesis of blood clotting factors. It is present in human

milk and absorbed efficiently. Because it is fat soluble, it is present in greater concentrations in

colostrums and in the high fat hind milk (Kries, et al; 1987), although the increased volume of

milk as lactation progresses means that the infant obtains twice as much vitamin K from mature

milk as he does from colostrums (Canfield, et al; 1991). Water-soluble vitamins, unless the

mother's diet is seriously deficient, breast milk will contain adequate levels of all the vitamins.

42
Since most vitamins are fairly widely distributed in foods, a diet significantly deficient in one

vitamin will be deficient in others as well. Thus an improved diet will be more beneficial than

artificial supplements. With some vitamins, particularly vitamin C, a plateau may be reached

where increased maternal intake has no further impact on breast milk composition (Fraser &

Cooper, 2013)

Minerals

The casein-protein in cow's milk interferes with iron absorption. Although iron in breast milk is

lower than in formula, it is absorbed five times as well and breastfed infants are rarely deficient

in iron (Riordan, 2016). The full term infant who is breastfed exclusively maintain iron stores for

the first 6 months of life (Lawrence & Lawrence, 2016). Generally, iron is added when the infant

begins solids at 6 months. Preterm infants need iron supplements earlier. All formula-fed infants

should receive formula fortified with iron (APP & ACOG, 2014). Sodium, calcium and

phosphorus are higher in cow's milk than in human milk. This difference could cause an

excessively high renal solute load if formula is not diluted properly (Mckinney, et al; 2011).

According to AAP (1997), the fluoride levels in human milk and in commercial formulas are

low. This mineral which is important in the prevention of dental caries, may cause spotting of

the permanent teeth (Fluorosis) in excess amounts. It is recommended that a fluoride supplement

be given only to those infants not receiving fluoridated water after 6 months of age.

Fluids

The fluid requirement for normal infants is about 80 to 100ml of water per kilogram of body

weight per 24 hours (Behrman, Kliegman, & Arvin, 1996). In general, neither breastfed nor

formula fed infants need to be fed water, not even those living in very hot climates. Breast milk

contains 87% water, which easily meets fluid requirements Feeding water to infants may only

43
decrease caloric consumption at a time when infants are growing rapidly (Wong, el al; 2002).

Furthermore infants have room for little fluctuation in fluid balance and should be monitored

closely for fluid intake and water loss. Infants lose water through excretion of urine and through

insensible losses such as respiration. Under normal circumstances, infants are born with some

fluid reserve, and some of the weight loss during the first few days is related to loss of this fluid.

Enzymes

Breast milk contains enzymes that aid in digestion. Pancreatic amylase, necessary to digest

carbohydrates is low in the newborn, but present in breast milk. Breast milk also contains lipase

to increase fat digestion (Mckmney, et al; 2011).

Anti-infection factors

Leucocytes: During the first 10 days there are more white cells per milliliter in breast milk than

there are in blood. Macrophages and neutrophils are amongst the most common leucocytes in

human milk and they surround and destroy harmful bacteria by their phagocytic activity (Fraser

& Cooper, 2013).

Immunoglobulin's: Five types of immunoglobulin have been identified in human milk: IgA,

IgG, IgE, IgM and IgD. Of these, the most important is IgA which appears to be both

synthesized and stored in the breast. Although some IgA is absorbed by the infant, much of it is

not. Instead it 'paints' the intestinal epithelium and protects the mucosal surfaces against entry of

pathogenic bacteria and enteroviruses. It affords protection against Escherichia coli,

pneumococci, poliovirus and the rotaviruses (Fraser & Cooper,2013).

Lysozyme: this binds to enteric iron, thus preventing potentially pathogenic E coli from

obtaining the iron they need for survival. It also has antiviral activity (against HIV, CMV and

HSV), by interfering with virus absorption or penetration or both (Fraser & Cooper, 2013).

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Bifidus factor: The bifidus factor in human milk promotes the growth of Gram bacilli in the gut

flora, particularly lactobacillus bifidus, which discourages the multiplication of pathogens

(Babies who are fed on cow's milk - based formulae have more potentially pathogenic bacilli in

their gut flora) (Fraser & Cooper, 2013)

Hormones and growth factor: Epidermal growth factor and insulin-like growth factor are

among the most fully studied of the growth factors and regularly peptides found in breast milk

and colostrums. They stimulate the baby's digestive tract to mature more quickly and strengthen

the barrier properties of the gastro intestinal epithelium. Once the initially leaky membrane

living in the gut matures, it is less likely to allow the passage of large molecules, and becomes

less vulnerable to microorganisms. The timing of the first feed also has a significant effect on

gut permeability, which drops markedly if the first feed takes place soon after birth (Fraser &

Cooper, 2013).

2.2 Theoretical Framework

Inch (2003), describes human milk as a God-given natural phenomenon, in which the standard is

valued utterly in order to provide the comprehensive nourishment to the neonate. The hormonal

and immunological constituent provides growth and development to the brain contributing to the

motor and sensory skills (Ackerman 2004). Moreover, according to Miller-Keane (2003), these

countless advantages include emotional attachment, economically sound and physical

remuneration to the mother’s wellbeing. WHO assemblage (2001) stated that a newly born must

receive exclusive breastfeeding up until the age of six months and it refers that nothing but the

mother’s milk. The continuation with the complementary will proceed until the child reaches age

two. Child needs not to drink water after the sufficient feeding is provided (Inch 2003). WHO

45
stated exclusive breastfeeding as an ultimate health promoting disease preventing action a new

mother can do to protect her newborn baby and herself (Craig & Dietsch 2010.)

Despite the support from the global health departments, the exclusivity of infant feeding, among

primigravid mothers are short-lived. Meanwhile, breastfeeding initiation rates are escalating; the

concern of reducing on the first 4- 8 weeks postnatal is advanced (Marrone, Vogeltanz-Holm &

Holm 2008). Studies revealed that there is an ample inconsistency between the duration and the

total amount of incidence that actually has been accomplished. Relatively among all the

developed countries, Australian and European women were seen to breastfeed more likely in

longer duration (Furber 2008).

Adequate knowledge on exclusive breastfeeding is a central implement that navigates the course

of breastfeeding stability and distinctiveness amongst mothers. Insufficient and defective

information with absence of support throughout this practice leads to immature cessation of

breastfeeding. Primigravidas are a vulnerable group with approximately more than half of the

percentage of early breastfeeding dropouts being primiparas who are deficient of involvement

and dependable intelligence of exclusive breastfeeding compared to multiparas.

Lack of confidence to exercise existing learnt knowledge leads to shyness, insecurity and

frustration resulting to optional infant feeding methods. Health professionals are thus, responsible

for conceivable envelopments that yield to an upsurge of exclusive breastfeeding by centering

extra determinations to primiparas on the significance and structuring self-confidence of

breastfeeding practices and knowledge throughout the prenatal, natal and postpartum period.

(Laanterä, Pölkki, Ekstrom & Pietilä 2010.)

Fairbrother & Stanger-Ross (2009) mentioned that the majority of mothers apprehend the health

benefits of breast milk to their infants with correspondence to it being the ultimate meal for

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newborns. In addition, breast milk benefits to the immune system of infants inhibiting infantile

infections like gastrointestinal and respiratory. Breast milk is well acknowledged for its

abundance in minerals, maternal antibodies and basic nutrients consisting of proteins, vitamins

and carbohydrate. The reconstitution being well combined, nitrifying and compatible to the

baby’s metabolic system making it most convenient meal for babies. Moreover, bonding and

familiarizing by closeness, tender touching, seeing and smelling one another during each feed and

vice versa is a mutual aim and intent for breastfeeding.

Almost all mothers pass through both short and long term physical challenges during

breastfeeding. Particularly, primigravidas become exposed with the physical challenges

associated with exclusive breastfeeding that seems slightly unexpected for them. Short and longer

term physical impacts caused a number of women to feel surprised about the physicality of

exclusive breastfeeding. Majority are astounded by the intensity and extent of discomfort and

pain which might be excruciating consequently, to compromise baby-mother relationship.

Occasionally, triggering hesitance to continue the practice secondary to physical vulnerability. A

few may experience “sore nipples” which is the package of challenges whereas mastitis (breast

infection) is also a complication that content serious emotional and physical consequences, as a

outcome resulting in anatomical changes which is a great challenge. (Kelleher 2006).

On the other hand, Kelleher (2006) mentioned that other unanticipated nature of somatic

implications including, increased sensations during the sucking process, leakage, latching,

letdown and immobility. Among, the most commonly cited specific forms of pain and discomfort

related to exclusive breastfeeding are engorgement, nipple pain, raw breasts, cracked and

bleeding nipples, blisters and uterine contractions or occasionally termed cramping or after pains.

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Psychological factors in addition, influence the duration or continuation of breastfeeding.

Primigravidas endure with psychological factors that directly affect exclusive breastfeeding. The

first aspect is considered as mother´s self confidence in her mothering ability or mothering self-

efficacy, with assurance to the natural supremacy of breastfeeding, “they get great satisfaction

watching her baby emptying the bottle”. After delivery there comes rapid changes in mother´s

life where she should proof her ability to be flexible and adapt her life according to demand of

new baby which becomes a great challenges for mothers to change their day to day life, a few

adjust while others expect their babies to. Stress, postnatal depression, mother´s level of self

esteem, breastfeeding self efficacy and anxiety have also shown their influence in interval of

exclusive breastfeeding. (Brien et al. 2009.)

In order to reduce morbidity and mortality rate, the breastfeeding support team must be more

dynamic and vigorously up-to date with the follow ups. It is crucial for a health provider to

recognize and distinguish the needs of guidance exclusively regarding the breastfeeding

continuation of primigravidas until the 6 months of the baby’s live (McCann et al.2010). Support

of family members especially father´s of new born baby play an active role in exclusive

breastfeeding whereas the unsupportive behavior and negative attitude of spouse can create the

situation challenging and decrease the initiation of breastfeeding in mothers. (Laanterä et al.

2010.)

Finnish maternity and child care system

The ministry of social affairs and health in relationship with National institute for health and

welfare THL and the social insurance institute of Finland KELA in conjunction with the

municipal central hospitals coordinate to form a standardized protocol that runs the maternity and

child health care services operating as a part of the Finnish National Health Care clinics. This

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protocol is synchronized by nation-wide strategy tabulated to cater for all Finnish citizens and

residing families since the 1940s.The core target is supporting expectant families perinatally,

monitoring the babys’ growth and developmental milestone by granting basic needs and a safe

environment for the baby and its family (Kouri & Kemppainen, 2000). Endowing free maternity

care for all its citizens and residing families including; promotive, preventive, curative and

rehabilitative services preserves infant and maternal morbidity and mortality rate at lowest

percentiles. (Ministry of social affairs and health 2011.)

The system guarantees that primigravidas get approximately 12 and 15 systemic focused

antenatal visits commencing at the first trimester at eight to 12 weeks with a doctors’ past

medical history, gynecological-obstetric examination, monitor vital signs (blood pressure, weight,

antenatal profile (hemoglobin level, blood grouping and rhesus factor, urinalysis, HIV, Syphilis

and hepatitis), and biophysical profile (fetal heart rate, movement and amniotic profile).

Consecutively visits are conducted by a public health nurse monthly until the third trimester

followed by two weekly visits until birth. However, a total of two three visits must be carried out

by a physician. Gratis ultrasonic examination to rule out any fetal abnormality and to clarify the

biophysical profile is recommended at the 12th-16th week. Nevertheless, the course is dictated by

the medical needs of the mother. Daily healthy living habits and proper nutrition education is

offered, preferences concerning delivery and infant feeding are reviewed in particulars with

accountable health professions and concluded decision is agreed upon wellbeing of both the

mother and the baby. (Ministry of social affairs and health 2011.)

Delivery preparation and counseling services to both parents-to-be are offered by delivery fear

specialized mid-wife who discusses the different stages of delivery and expectations with the

Primigravidas. It is also possible to have psychologist appointment if the state is complex. In

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addition, a maternity pack, containing babys’ clothing and articles crucial for new-born care or a

tax-free summation of 140 Euros for one baby three packs or 420 Euros for twins and six packs

or 840 Euros for triplets is an alternative granted. Maternity clinic refers clients to accessible

closest delivery hospital. Approximately 99% of births in Finland are public hospital births.

Nonetheless, although Finnish health care system does not support home delivery, roughly six

percent of mothers engross and prefer to deliver at home. However, in a period two weeks after

delivery, a nurse appoints to the new family in their home to make sure the well-being of both the

mother and newborn. Thereafter, baby’s health is supervised in child care clinic (Neuvola). (The

social insurance institute of Finland 2012.)

Maternity clinics systematize explicit family training for primigravida couples following the 2001

Finnish Ministry of Social Affairs and Health manual issued to maternity and child care clinic

workers reinforcing the early role of fathers on child care. It emphasizes the importance of both

parents as main care givers and benefits of safe Baby-father relationship in case of unexpected

absence of the mother as a compensatory mechanism. In addition, Infants with two primary care

givers have proved to possess sense of belonging and security comparing to infants with one

primary care giver. Father groups designed to orient, mould and support anticipating fathers by

familiarizing and teaching matters concerning pregnancy, delivery and fatherhood are also

offered. It prolongs to postpartum period strengthening positive experience improving confidence

level as new parents. This helps endorse and maintain mothers’ social life outside the family

circle and reduce incidences of Post-partum depression. (Kapanen 2007.)

According to Kapanen (2007), online maternity clinic has also been conventional creating

efficiency to current maternity services. Net Clinic delivers advance information to families about

50
pregnancy, delivery, nurturing infants and family welfare. However, ethical and patient rights

precisely confidentiality are highly stringent.

Theory of planned behavior

Encouraging Primigravidas to exclusively breastfeed is a chief focal point of Baby Friendly

Initiatives. According to the Theory of Planned Behavior (TPB) developed by Icek Ajzen in

1985, behavior is a function of intention to perform a routine. Breastfeeding outcomes are

exceedingly prejudiced by social support and this theory explains instigation, stability and period

of breastfeeding being subjective. Social support however is further alienated into formal and

informal execution. Breastfeeding information, demonstration and verification of current

evidence based breastfeeding knowledge and practices delivered by a nurse, lactation consultant,

peer counselor, nutritionist are Formal implementation methods. The mechanism engrosses

single/group once or incessant sessions with a nurse throughout Women Infant Clinic WIC

clinics. Emphasizing on the mothers’ concerns articulated during the session crafts assurance,

confidence and synergizes the verdict to breastfeeding. (Vari 2000.)

The course of social support ought to commence prenatally and persist throughout the Perinatal

period therefore, harmonization of formal and informal (including; husband, mother, relatives

and community) social support providers should be scrutinized in progress for preferred results.

A nurse thus needs to assess and highlight components that must be taken in hand as an element

of the evaluation in the theory of planned behavior consisting support provider, chances of peer

interaction, prenatal support and throughout. These components influence and aid a nurse to

categorize motives following the behavioral patterns and decision making of mothers on infant's

feeding. Nonetheless, the significance of social support for breastfeeding is an inventive that is

legitimated by health care providers. Nevertheless, the challenge remains in classifying

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mechanisms of support and appropriately fit them together to provide women with the most

favorable prospects to advance the effects of their breastfeeding efforts. (Vari 2000.)

Theories on attitude

Fritz (2008), defines attitude as an optimistic or pessimistic reaction of people, substance,

occurrence, behavior, thoughts, or anything within the surroundings. It is very essential to

uncover the meaning following the reaction and its atmosphere. Usually, positive attitude

improvises to success and satisfaction, whereas the negative portrays failure. Attitude in social

psychology is very significant to comprehend. Moreover, attitude has numerous outcomes.

Firstly, it influences perception, performance and verbalization. Secondly, it manipulates

emotional well-being both mentally and physically. Lastly, it depends upon the individual’s

capacity to fulfill one’s objective.

According to Gagne’s theory, (1985) attitude is defined as;

Acquired internal states that influence the choice of personal action toward some class of things,

persons or events (Gagne 1985; Driscoll 2005.)

The original concept of attitude consists of three major components as Affective Behavioral and

Cognitive (Kwon & Vogt 2010). The Affective ‘A’ confirms the expressions from emotions and

how an individual feels toward an impact of an object. The behavioral ‘B’ determines the

conducting manners that are reflected after how the individual has reacted towards the force of

contact. Finally, the Cognition ‘C’ interprets the determination of the individual’s belief and

credence after the collision of an experience. The triumph of trio ABC consequently,

accompanies how an individual’s attitude toward a subject or an object. (Kwon&Vogt, 2010; Mc

Leod 2009.)

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According to Fritz (2008), the components of negative and positive attitudes are clearly divided,

the negative consisting; laxity, unawareness, over poise, sarcasm, lethal, hasty, rage, irresponsible

and languid etc. Whereas, the positive consisted; heartening, contentment, attentive, shows

positive reception, supportive, forecast in advance, vigilance and preciseness (Kwon & Vogt

2010; Fritz 2008). The distinction between the positivity and negativity solely depends upon the

affective branch of an attitude in which an individual echoes the reaction on the basis of

precedent experiences candidly or circuitously (Kwon & Vogt 2010).

Attitude lends a hand for an individual to survive the milieu through the function knowledge and

utilitarian. Similarly, expands and sustain association within the society therefore, value-

expressive and impression management function of attitudes are ordinary on site (Hogg &

Vaughan 2005). According to cultural variances, attitude accentuate on the individual to illustrate

uniqueness in independent western cultures whereas, in inter-dependent ethnicity underlines

assembly of synchronization and harmony (Wang 2012; Webb & Sheeran 2006).

According to Daniel Katz Functionalist theory of attitudes, the objective or goal of an individual

depends upon the individual’s attitude toward it (Wang 2012). Katz has divided into four major

types; Instrumental, Knowledge, Value expressive and Ego Defensive. Instrumental attitude

refers to as protruding attitude towards its depth of beneficiary. An object that fulfills the desired

outcome favors the significant attitude. Knowledge favors the theoretical clarity and stability in

which the environment is structured systematically. The theory of knowledge provides the

individual with confidence and reliable. The complexity of life can be brought upon in a standard

approach. (Hogg & Vaughan 2005). Value-expressive simplifies to adopting own individual

values and rituals. Culture and society may be involved but it is depended solely upon an

individual’s self reflection and ease. Ego-defensive theory supply as a defense mechanism system

53
in an individual to protect self harm and vindictive reality in the modernizing globe. (Mc Leod

2009; Wang 2012.)

Moreover, Katz theory describes when the functional theory is not applicable and when the

individual feels barrier then it is imperative to revolutionize the principal motivational and

personal requirements (Mc Leod 2009; Wang 2012).The learning theory derives from classical

conditioning in which bilateral parties are involved in emotional reaction after learning the non-

verbal reactions whether pleasant or foul. The attitude becomes habitual as it used to being

learned and doesn’t need the full explanation. In Instrumental conditioning derives a delightful

reaction usually in positive consequences. Observational learning is similar to mimicking the

learned behavior that has been repeatedly reinforced. (Webb & Sheeran 2006; Armitage &

Conner 2001.) On the contrary, Cognitive dissonance theory is a theory when there is a

contradiction between self-attitude, belief and behavior with the existing alternative. These

relations can be consonant, dissonant and irrelevant. (Metin & Camgoz 2011.)

2.3 Empirical Reviews

Ukegbu (2011) “Determinants of breastfeeding patterns among mothers in Anambra State,

Nigeria” Exclusive breastfeeding for the first 6 months of life is still rare among nursing

mothers. This study aimed to identify the factors influencing breastfeeding practices among

mothers in Anambra State, Nigeria. A prospective cohort study was conducted in three

comprehensive health centres of Nnamdi Azikiwe University Teaching Hospital (NAUTH),

Anambra State, between September 2006 and June 2007. The breastfeeding practices of 228

nursing mothers were assessed at enrolment when attending the maternal and child welfare

clinics for BCG immunisation, and at follow-up visits at 6, 10, 14, 20 and 24 weeks. In addition,

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four focus group discussion sessions (one in each centre) were held, involving a total of 35

nursing mothers. Most mothers 190 (83.3%) were aged between 20 and 34 years. The majority

(208, 91.2%) had good or very good knowledge of breastfeeding. The main source of

breastfeeding education was government health facilities (80.85%), but only 110 mothers

(48.2%) initiated breastfeeding immediately (<1 hour) after delivery. The exclusive breastfeeding

(EBF) rate fell from 143 (62.7%) at birth to 85 (37.3%) at 24 weeks. EBF was significantly

associated with older maternal age, higher parity, delivery at a government facility, a positive

family attitude towards EBF, and breastfeeding education from a government health facility

(p<0.05). Focus group discussion showed that mothers believed that adequate nutrition and

physical, financial and emotional support to them would increase EBF practice. The rate of EBF

was low among the mothers, and the factors identified that may influence its practice have

important implications for breastfeeding intervention programmes. Activities to promote EBF

should be focused on specific groups of women and locations in which it is poorly practised. In

addition, support to the mothers is necessary.

According to Janet Danso (2014). “Examining the Practice of Exclusive Breastfeeding

among Professional Working Mothers in Kumasi Metropolis of Ghana” This study examined

the practice of exclusive breastfeeding among professional working mothers in Kumasi

Metropolis of Ghana. The study design used for this research was cross sectional survey. The

study population consisted of professional working mothers, aged 40 or younger, who were in

full-time employment and working in Kumasi metropolis of Ghana.

Purposive and random samplings were also used and sample size was 1000. Questionnaire was

the research instrument used in this study. From the study findings, even though the respondents

were well-informed about exclusive breastfeeding, 48% of professional working mothers were

55
able to practice exclusive breastfeeding and 52% could not practice exclusive breastfeeding

according to World Health Organisation recommended practice of exclusive breastfeeding.

The study concluded that professional working mothers find it difficult to exclusively breastfeed

their babies and full time employment status and family members’ influence undermine the

practice of exclusive breastfeeding. It was recommended that government must guarantee that

workplace is free of harassment and discrimination against women who prefer to breastfeed their

babies through appropriate mechanisms and employers must provide breastfeeding and

expressing facilities at the work place to be used by breastfeeding employees and these facilities

have to be hygienic, comfortable and private and include hand washing and milk storage

facilities.

Jennifer A. Tyndall (2016). “Knowledge, Attitudes and Practices on Exclusive

Breastfeeding in Adamawa, Nigeria” Despite the efficacy of the Early Exclusive Breastfeeding

(EBF) approach to child nutrition in reducing child mortality, few nursing mothers in Nigeria are

willing to adopt this method of feeding. This research was therefore undertaken in order to assess

the Knowledge, Attitudes and Practices (KAP) on EBF of antenatal clinic attendees in North-

eastern Nigeria. Cross Sectional Community Survey. Two hundred and fifty expectant mothers

attending the ANC clinical sessions at Specialist Hospital, Yola, Adamawa State, were recruited

for this study. The mean age of the women was twenty eight. Data was generated from a corpus

consisting of health talks and questionnaires on the respondents’ KAP on EBF during these

clinical sessions at this health facility. The results of the survey revealed the problems that inhibit

or reduce the practice of exclusive breastfeeding to include the following: the assumption that

colostrum is stale milk--84%; breast milk lacks sufficient nutrients--approximately 62%; and

expressed breast milk is contaminated milk--just under 98%. With respect to the mother’s attitude

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to EBF, 60% believed that this method of feeding would flatten their breasts and 78% that EBF

causes respiratory tract infections. Furthermore, over 64% thought that food supplements were

ideal for infants and that EBF was suitable only for working mothers. These results clearly

demonstrate the lack of awareness and education on EBF. From both a national and international

perspectives, poor maternal nutrition, inadequate support from spouses, family and even nurses

and doctors are some of the constraints that limit the rate of practicing exclusive breastfeeding.

Public health initiatives on the benefits of EBF need to be addressed, particularly at antenatal

clinics and also through outreach programs that target mothers in the rural communities who have

limited access to health care.

According to Swastika Chhetri (2018). “Factors affecting exclusive breastfeeding (EBF)

among working mothers in Udupi taluk, Karnataka” Employment of the mother is considered

to be one of the most important barriers to exclusive breastfeeding (EBF). To study the factors

influencing EBF practices among working mothers in Udupi taluk. A community-based cross-

`sectional study was conducted among breastfeeding mothers employed in any form of

occupation having an infant less than six months old (n =137). Interviewer administered

structured questionnaire was used to collect data. Chi-square test was performed to find the

association between different variables and EBF. The prevalence of EBF among working mothers

was found to be 17.5% although 75% of them had adequate knowledge on EBF and its benefits.

Around 52% of the mothers did not receive any maternity leave benefits. Only 11% of mothers

were allowed breaks in between working hours but none of the mothers were provided with

crèches at their workplace. The commonest reason to discontinue EBF was early resumption of

work after childbirth. Factors such as educational status of working mother and her husband,

occupation of husband, place of delivery, sex of the newborn, frequency of breastfeeding per day,

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practice of expressing and storing breastmilk before leaving for work and breaks during working

hours were found to be statistically significant with EBF practice. These findings emphasize the

need to guarantee the support to breastfeeding policies at workplace which in turn would

motivate working mothers to continue EBF after resuming work.

2.4 Summary of Literature Reviewed

The benefits of breastfeeding for mothers and infants have been widely recognized and

researched. Studies have shown that breastfeeding is superior to infant formula feeding because

of its protective properties against illness, in addition to its nutritional advantages. Considering

the extensive benefits of breastfeeding, the World Health Organization, United Nations Children

Fund and the American Dietetic Association recommend exclusive breastfeeding of infants for

the first six months and continued breastfeeding with complementary foods up to 24 months of

age. Despite widespread efforts to encourage breastfeeding, the rates in Nigeria have remained

low. Many demographic factors such as maternal age, education, socioeconomic status, cultural

factors, and social support have been shown to potentially influence a woman’s decision to

breastfeed. Along with a number of demographic factors, poor or negative attitudes toward

breastfeeding have been shown to be barriers to initiating and sustaining breastfeeding. Previous

studies have shown that mothers who do not breastfeed or individuals who do not support

breastfeeding have negative attitudes towards breastfeeding. Because the decision to breastfeed

is often made long before a woman becomes pregnant, breastfeeding promotion programs should

focus on educating women during their antenatal classes. In order to facilitate positive attitudinal

changes in individuals, health care professionals with adequate knowledge and positive attitudes

about breastfeeding are critical. Health Educators who received nutrition education, including

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optimum infant feeding methods, are considered advocates of breastfeeding.

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 CHAPTER THREE

METHODOLOGY

The purpose of this study was to examine demographic determinants of exclusive and non-

exclusive breastfeeding among nursing mothers in Nnamdi Azikiwe University Teaching

Hospital, Nnewi, Nnamdi Azikiwe University Teaching Hospital, Nnewi. The study was

conducted to specifically assess the influence of mother’s age, education, occupation, income

and family/friends views in the practice of exclusive and non-exclusive breastfeeding of infants.

To achieve this purpose, the research design, population, sample and sampling technique,

instrumentation, validation, administration of the instrument, and statistical techniques used in

this study are described below.

3.1 Research Design

Ex-post-facto research design was considered suitable for this study since there was no

manipulation of information from the respondents. Razaq, & Ajayi, (2000), explained that ex-

post-facto is undertaken after the events have taken place and the data are already in existence.

In ex-post-facto research design it is difficult to manipulate independent (mother’s age,

education, occupation, level of income, and family/friends views) variables because data are

already inexistence.

3.2 Settings of Study

The study setting; Nnamdi Azikiwe University Teaching Hospital, Nnewi is situated in the

southern part of Anambra State, the Nnewi North LGA has a total population of about 147,788

(According to National Population Census, 2006) people with the ratio of 51.5 % and 48.5 % to

females and males, respectively. The study area has a land area coverage of 669.7 km2 of which

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64.5 % of the population lives in the urban areas while 35.5 % are rural residents.

3.3 Population

The population of this study comprised all nursing mothers with infants who are exclusively and

non- exclusively breastfed, attending Nnamdi Azikiwe Teaching Hospital, Nnewi, Nnamdi

Azikiwe University Teaching Hospital, Nnewi. The population was estimated at 560 (Anambra

State Ministry of Health, 2019).

3.4 Sample and Sampling Techniques

A simple random sampling was employed to ensure equal chance of being selected for the study,

numbers were assigned to each of the departments in charge of children well being. Thereafter,

the assigned numbers were written on pieces of papers, folded and dropped into three different

containers according to their respective zones. The researcher then asked one of his research

assistants to dip his hand into a container and pick out a number. Nursing mothers of infants

aged 4-24 months, visiting the ten randomly selected hospitals were purposively selected for the

study. The following selection criteria were used for participation:

1. Mothers who are breastfeeding currently

2. Mothers having infants/ children between 4-24months.

Infants aged 4 months to 24 months were considered suitable for this study in order to ascertain

whether the mother practices exclusive or non-exclusive breastfeeding preceding the study.

This was in agreement with the study done by Ekele & Hamidu, (1997), that babies whose age

peaked at 4-6 months were said to have been either exclusively or non-exclusively breastfed.

Infants whose age peaked at 24 months were also considered because they were still attending

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postnatal clinics and it is the age the infant is expected to be weaned from breast milk as

recommended by WHO (2014).

Such nursing mothers provided information based on their history of feeding methods

preceeding to the study. Out of a total of 560 nursing mothers who attended Nnamdi Azikiwe

University Teaching Hospital post-natal clinics in Nnamdi Azikiwe University Teaching

Hospital, Nnewi, 50 were selected purposively and used as sample size for this study. All

nursing mothers who agreed to participate and also possess the above mentioned criteria, were

served with a copy of the questionnaire. 45 questionnaires were duely completed and returned,

out of which 38 exclusively breastfed, while only 7 mothers practiced non-exclusive

breastfeeding preceding the study.

After obtaining the informed verbal consent, the mothers were visited at the respective post-natal

clinics and the questionnaire was administered to the nursing mothers for completion.

3.5 Research Instrument

Data was collected using structured and self-developed questionnaire and some items of the

questionnaire were adopted from similar studies such as Adamu, (2002), Salami, (2016), Mundi,

(2015), Nigeria Demographic and Health Survey (NDHS), (2015), and Awogbenja, (2010). The

questionnaire consisted of three sections, A, B, and C with a total of 17 items. Section A consists

of four (4) items on demographic characteristics of nursing mothers. Section B consists of five

(5) items on opinions of mothers on methods of breastfeeding. Section C contains eight (8) items

on feeding patterns by nursing mothers.

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3.6 Validity of Instrument

To ascertain the face and content validity of the questionnaire, the prepared questionnaire was

distributed to four experts within and outside the Department of Health Science Technology,

Nnamdi Azikiwe University Awka. They served as jurors for vetting and ascertaining the face

and content validity of the instrument. The corrections were implemented and a final

questionnaire was produced and used for data collection. Before the questionnaire was

distributed, eligible mothers were given explanations concerning the study and how the

questionnaire was to be filled by the respondents, and upon verbal consent to participate. The

questionnaire was distributed by the researcher, two trained research assistants and three trained

nurses on duty. A total of 50 questionnaire was administered, out of which 45 were duely

completed and returned to the researcher. The researcher with his two research assistants, visited

each of the randomly selected hospital on a scheduled date.

Instructions were given on how to complete the questionnaire. Upon completion, the researcher

used a total of 45 questionnaire for statistical analyses.

3.7 Procedure of Data Collection

Five women who matched the inclusion criteria were selected to answer questionnaires for

piloting. Questionnaires were pretested for purposes of comprehension, readability, and easiness

of administration. After piloting, there were no major corrections needed since according to their

responses the questions were clear and understandable.

In the data collection process, questionnaires were administered among subjects in three different

settings. These were; Uruagu Nnewi, Nnewichi, and Otolo Nnewi within the study setting.

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Eligible mothers were those who were available at the venue during the time of administration

and who willingly accepted to participate in the study after reading through the consent form.

These mothers were women who lived or worked at these venues, mothers who had come to the

hospital with their children for routine medical checkups and those who are available to worship

at the church. The purpose of this study was discussed with participants including the

instructions on how to answer the questionnaire. All participants were handed with equal set of

questions in English language. Questionnaires were answered unassisted and returned to the

researcher on same day after completion in English. Completing a questionnaire on average took

about 7 to 10 minutes. Altogether, 120 women agreed to participate the study.

3.8 Data Analysis

As the primary purpose of this study was to assess the influence of demographic determinants of

exclusive and non-exclusive breastfeeding among nursing mothers, descriptive statistics of and

inferential statistics were used. In descriptive statisticst, frequencies and percentages and cross

tabulation statistics were used to answer the research questions. A non-parametric statistics of

chi-square was employed to test the formulated research hypotheses.

3.9 Ethical Consideration

Ethical approval for the study was obtained the Nigeria Health Service prior to data collection.

Cautious thoughtfulness was given to protecting the respondents during the study, including

during the production of the written report. The study, along with the issue of voluntary

participation, was explained in the introductory letter that contained the questionnaire.
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The study was introduced with a statement welcoming participation, followed by an account of

the following factors to guarantee that ethical considerations were being met: (a) investigator, (b)

introduction/purpose, (c) procedure, (d) risk/side effects, (e) benefits, (f) voluntary

participation/withdrawal and (g) confidentiality.

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