International Journal of Pediatrics and Adolescent Medicine 5 (2018) 39e48

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International Journal of Pediatrics and

Adolescent Medicine
journal homepage: http://www.elsevier.com/locate/ijpam

Original research article

The impact of maternal socio-demographic characteristics on

breastfeeding knowledge and practices: An experience from
Casablanca, Morocco
Mouna Habibi a, *, Fatima Zahra Laamiri a, c, Hassan Aguenaou d, Loubna Doukkali a,
Mustapha Mrabet a, Amina Barkat a, b
a
Research Team on Health and Nutrition of Mother and Child, University Mohammed V, Faculty of Medicine and Pharmacy, Rabat, Morocco
b
National Reference Center for Neonatology and Nutrition, Children's Hospital, Ibn Sina University Hospital Centre, Rabat, Morocco
c
Higher Institute of Nursing Professions and Technical Health, Rabat, Morocco
d
Joint Unit for Nutrition and Food Research at Ibn Tofaïl University (URAC 39), National Centre for Nuclear Energy, Sciences and Technology (CNESTEN),
RDC-Nutrition AFRA/AIEA, Morocco

a r t i c l e i n f o a b s t r a c t

Article history: Background: Breastfeeding is universally recognized by the World Health Organization as the best way of
Received 11 September 2017 feeding infants. Therefore, several countries have initiated health promotion interventions to support
Received in revised form successful breastfeeding based on the factors influencing breastfeeding outcomes.
24 December 2017
Objective: To examine the association between the knowledge of breastfeeding and maternal socio-
Accepted 18 January 2018
Available online 1 May 2018
economic and demographic characteristics, and to determine any impact on child nutritional status.
Methods: A cross-sectional study using both qualitative and quantitative methods was conducted with
mothers of infants aged six- to twenty-four months. Data was collected by a semi-structured ques-
Keywords:
Breastfeeding
tionnaire and face-to-face, in-depth interviews with mothers to get an insight into their breastfeeding
Lactation perceptions and experiences. Educational achievement and occupational class were used as indicators of
Human milk socio-demographic status. Nutritional status was assessed by anthropometric measurements.
Child nutrition Results: A significant relationship between exclusive breastfeeding and the mother's education (P < .001)
Nursing and socio-economic status (P < .001) has been highlighted. A significant link was pointed out between
Nutritional status breastfeeding and length-for-age Z score (LAZ) (P < .001), and weight-for-age Z score (WAZ) (P ¼ .005).
Moreover, a strong association was found between maternal employment and exclusive breastfeeding
(P < .001).
Conclusions: Our findings shed some light on challenges faced by mothers, as well as an association
between socio-demographic characteristics and practices for facilitating exclusive breastfeeding to guide
the mothers in breastfeeding management.
© 2018 Publishing services provided by Elsevier B.V. on behalf of King Faisal Specialist Hospital &
Research Centre (General Organization), Saudi Arabia. This is an open access article under the CC BY-NC-
ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

1. Introduction do not reach optimal growth. The prenatal and postnatal diets are
the major causes of stunted children [1].
The health benefits of breastfeeding are unquestionably According to the World Health Organization (WHO), breast milk
admitted throughout the world. is the best nutrition reinforcing optimal growth in early infancy
Trials theorized that almost 39% of the world's child population [2,3]. However, the establishment of exclusive breastfeeding (EB)

, BP 6527,
* Corresponding author. Research Team on Health and Nutrition of Mother and Child, Emergency Medical Department, University Children's Hospital Rabat-Sale
Rue Lamfadel Cherkaoui Rabat Institut, Morocco.
E-mail addresses: mouna.habibi@um5s.net.ma (M. Habibi), fatilamir1970@yahoo.fr (F.Z. Laamiri), aguenaou2014@gmail.com (H. Aguenaou), L_doukkali@yahoo.fr
(L. Doukkali), mrabetmp@gmail.com (M. Mrabet), barakatamina@hotmail.fr (A. Barkat).
Peer review under responsibility of King Faisal Specialist Hospital & Research Centre (General Organization), Saudi Arabia.

https://doi.org/10.1016/j.ijpam.2018.01.003
2352-6467/© 2018 Publishing services provided by Elsevier B.V. on behalf of King Faisal Specialist Hospital & Research Centre (General Organization), Saudi Arabia. This is an
open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
40 M. Habibi et al. / International Journal of Pediatrics and Adolescent Medicine 5 (2018) 39e48

until six months of age is still commonly affected by the miscon- 2.4. Eligibility criteria
ception of the breastfeeding process [4].
From the age of six months, children require a food diversifi- Inclusion Criteria: In this study, we selected all nursing mothers
cation to prevent growth retardation. Impaired feeding in the first of children aged 6e24 months.
years of life might induce malnutrition, which has shown correla- Exclusion Criteria: Children having any congenital or metabolic
tion to short-term injurious repercussions d essentially retarded diseases capable of influencing growth, history of acute infection or
growth and increased child morbidity and mortality [2,5]. diarrhea 15 days or less before the survey were excluded.
The priority of fighting childhood malnutrition and mortality
has been enshrined in the United Nations' Millennium Develop- 2.5. Sample size and sampling procedure
ment Goals (MDGs). Therefore, dealing with neonatal mortality,
which is to a large extent recognized to be related to delayed Based on Lorenz's [13] formula for calculating sample size, and
breastfeeding initiation, is fundamental to reach the MDG 4 tar- assuming a P (national prevalence of exclusive breastfeeding of a
geting the reduction of child mortality in developing countries newborn at term at the age of 6 months in Morocco) of 27%, an a of
[6,7]. 0.05 and a Za of 1.96, a minimum sample size of 250 nursing
In Africa, enhanced performance monitoring in Morocco mothers was required.
regarding the MDGs, notably MDG 4, over the past 15 years, has All in all, 297 questionnaires were completed, with a valid
been substantially efficacious, as the child mortality rate of children response rate of 90%. Twenty-six mothers refused to participate
under the age of five decreased by more than 60%, while the because they claimed that the interview will take too much time.
neonatal mortality goal remains out of reach [8].
Currently, Morocco's engagement to development aims to attain 2.6. Data collection
the new global Sustainable Development Goals (SDGs) to eradicate
extreme poverty, realign nutrition as crucial to evolution and raise Data was collected through an individual, face-to-face, in-depth
communal welfare by 2030. Indeed in 2016, the world formally interview with the selected mother, using a pre-tested and struc-
established the 2030 agenda for SDGs to confront challenges over tured questionnaire guided by previous literature. The question-
the next 15 years. Goal 2, above all, aims to end hunger and all types naire focused on identifying factors that may influence
of malnutrition and to carry out continual food production by 2030 breastfeeding choices and outcomes to explore the breastfeeding
[9,10]. experiences [14,15], practices and perceptions on breastfeeding
It is with these issues in mind that we aspired to evaluate constraints.
breastfeeding practices of nursing mothers and their knowledge of Two pediatricians assessed the validity of the questionnaire.
existing breastfeeding recommendations. Additionally, we sought Pre-testing was completed on 5% of the total respondents to
to address the motives and compulsions that drive women to wean determine whether the questionnaire was understandable, and
prior to the accepted scheduled time. Furthermore, we assessed corrections were made progressively. The face-to-face interviews
whether the type of breastfeeding influences child nutritional required almost 40 min.
status. The questionnaire had three parts. First, we gathered in-
formations on age, baby gender, education level, marital status,
2. Methodology mode of delivery, parental occupation, living environment, number
of children, rank among siblings, and health insurance coverage.
2.1. Study area Besides, informations on monthly income for household was used
for the determination of the lower, middle and wealthy social
This study was conducted in Ain Chock, which is a locality in the classes in Morocco using a broad definition of the middle class,
city of Casablanca, Morocco. According to data from the Moroccan adopted by the High Commission for Planning surveys based on a
General Census of Population and Housing of 2014, the Aïn Chock lower limit of 2800 Moroccan dirham (MAD) per month and an
District includes 89,013 households out of a population of nearly upper limit of 6736 MAD per month [16].
377,744 [11,12]. The second questionnaire section contained questions specific
to breastfeeding. Questions covered the following topics: maternal
knowledge and attitudes towards breastfeeding versus formula
2.2. Research design feeding, antenatal intent to breastfeed, knowledge and factors that
encourage or discourage mothers from the practice of exclusive
This was a cross-sectional study, undertaken from January to breastfeeding, exposure to media sources concerning breastfeed-
December 2016, on healthy urban children seen for routine primary ing, support networks including healthcare professionals and
healthcare at the twelve public health centers in Ain Chock district, friends/family, current infant feeding practices, and influential
Casablanca. family members' knowledge and practices regarding exclusive
breastfeeding.
2.3. Source and study population Twelve questions assessed the mother's knowledge of the
benefits of exclusive breastfeeding [17,18]. These questions covered
The sourced population consisted solely of mothers with the entire process of exclusive breastfeeding and its well-
infants whose age was between six and twenty-four months, documented benefits for the mother-infant dyad. Questions were
who were requesting vaccination or vitamin A/D supplementa- posed as agree or disagree.
tion for their children at the Ain Chock health facilities. Those Moreover, 12 questions focused on the breastfeeding behaviors
having any congenital or metabolic diseases influencing growth, of mothers in the postpartum period and the principal challenges
history of acute infection or diarrhea 15 days or less prior to the subsequently encountered [19].
survey were excluded. This selected population ensured the Eight breastfeeding features were submitted to mothers who
completion of the optimal duration of exclusive breastfeeding, completed our survey:
thus having better remembrance with regards their breast- 1) Mastitis/Breast abscess; 2) Full breasts/breast engorgement/
feeding practices. sore or fissured nipple; 3) Perceived insufficiency and low breast-
 M. Habibi et al. / International Journal of Pediatrics and Adolescent Medicine 5 (2018) 39e48 41

milk production; 4) Inverted, flat, large and long nipples; 5) Low 3. Results
breast-milk intake; 6) Being depressed, lacking in confidence,
worried, or stressed; 7) Short-term separation due to employment 3.1. Study participant demographics
outside the home; and 8) Health facility environment and family
members were not supportive. The overall analysis of the children recruited revealed that the
median age was 12 months with extremes of 6 and 24 months. The
12e24 months age group was the most predominant, with a sex
2.7. Assessment of nutritional status in children ratio of 1.34.
All infants included in the study were full-term and eutrophic.
Anthropometry is universally used as the gold standard mea- The mean birth weight was 3 Kg ± 200 g and the gestational age
sure for acute malnutrition in children beyond six months of age was 38 weeks ± 1.5.
and has proven value [20]. For the surveyed mothers, 87.2% were housewives, with more
The World Health Organization Infant Growth Standards were than half having attained a secondary education level (59.6%).
utilized to evaluate the Z-scores [21]. In Our study, we examined Moreover, the economic level of the household was average for
data for children with Z-scores less than minus two standard de- the majority of our participants (72.1%). The main characteristics of
viations (2 SD). our population are presented in Table 1.
Stunting was diagnosed on the basis of an international
consensus which says that children are stunted if their length-for- 3.2. Assessing malnutrition in infants
age Z-score (LAZ) is less than 2 SDs and severely stunted if their
length is under 3 SDs in comparison with the WHO Child Growth The analysis in Table 2 revealed a statistically significant dif-
Standards median for similar age and gender [22,23]. ference between the two genders for median LAZ (P < .001) and
Children were characterized as wasted children (weight-for- WAZ (P ¼ .019) below 2 SD. However, the distribution of the two
length Z-score (WLZ) < 2) and severely wasted children sexes according to nutritional status was statistically similar.
(WLZ < 3), using the WHO's Child Growth Standards [20,24]. Table 2 shows the overall distribution of nutrition indicators less
Furthermore, based on the growth standards of the WHO, se- than 2 Z-scores by gender at all ages.
vere underweight children were represented by having weight-for-
age Z scores (WAZ) less than 3.0 SDs and were free from any
congenital diseases [20,25]. 3.3. Knowledge of the benefits of exclusive breastfeeding
Data collectors were trained to use a data collection tool and
corresponding procedures for four days. Five final-year medical In order to meet the objective of our study, we performed a
students with practical experience in research studies collected descriptive analysis of mothers' knowledge of the benefits of
data. Public health nurses also helped investigators during
fieldwork. Table 1
Socio-demographic characteristics of infants and families.

Characteristics Overall population

2.8. Data analysis (N ¼ 297)

Infant characteristics
Statistical Package for Social Sciences (SPSS) was utilized to Child's age (months)a 12 [9e18]
analyze data. We applied a mixed-methods approach using both Child's age ranges b
qualitative and quantitative methods. 6-8 months 58 (19.5)
The statistical assessment of the quantitative variables was 9-11 months 83 (28)
12-24 months 156 (52.5)
performed by calculating the average ± standard deviation, or
Gender of the child b
median and interquartile range (IQR). Female 127 (42.8)
The normality of the distribution was evaluated using the Male 170 (57.2)
Kolmogorov-Smirnov (KS) test [26], but rejected at a P value < .05. Mother characteristics
The comparison of quantitative variables with normal distribution Mother's agec 29.72 (6.05)
Mother's age groups b
was carried out by the student t-test; when the parametric hy- Less than 20 Years 11 (3.7)
potheses were not satisfied, the Kruskal-Wallis test and the Mann- 20-29 Years 146 (49.2)
Whitney test were performed [27]. 30-39 Years 117 (39.4)
Qualitative variables were expressed in numbers and percent- 40-49 Years 23 (7.7)
Literacy b
ages and their associations were assessed using the Chi-square test
Illiterate 27 (9.1)
or Fisher's exact test. A value of P < .05 was considered significant Primary school 56 (18.9)
for all statistical analyzes. Secondary school 177 (59.6)
Higher education 37 (12.5)
b
Mother's professional activity
Housewife 259 (87.2)
2.9. Ethical consideration Paid worker 38 (12.8)
Household characteristics
This research received prior approval from the Institutional Monthly income (MAD)d 5000 (2700e6500)
Ethics Committee of the Faculty of Medicine in Rabat, Mohamed V Household economic levelb
Low 83 (27.9)
University, Morocco. The interview content was explained in detail
Medium 214 (72.1)
to respondents. Free and informed verbal consent was obtained at
the beginning of each investigation from all participants. Data Note
a
Values are expressed as median and interquartile.
collection and handling were done with strict confidentiality. b
Values are expressed as count and percentage.
Furthermore, all the women interviewed were free to withdraw c
Values are expressed as mean ± standard deviation.
d
from the study at all stages. MAD¼Moroccan Dirhams.
42 M. Habibi et al. / International Journal of Pediatrics and Adolescent Medicine 5 (2018) 39e48

Table 2
Distribution of low nutrition indicators by gender, in child's population.

Nutritional status Child's population p value

(Classification Based on growth indicators < -2 Z-scores) (N ¼ 297)

Boys Girls
n ¼ 170 n ¼ 127

LAZ < -2 Z-scores 2.5 [4;2] 2.5 [4;2] <.001*

Stunting Severely Stunted 27 (15.9) 9 (7.1) .400**
(LAZ < 2 Z-scores) Stunted 31 (18.2) 16 (12.6)
Combined 58 (19.5) 25 (8.4)
WAZ < -2 Z-scores 2 [2.5;2] 2 [3;2] .019*
Underweight Severely underweight 3 (1.8) 2 (1.6) .809**
(WAZ < 2 Z-scores) Underweight 16 (9.4) 4 (3.1)
Combined 58 (19.5) 25 (8.4)
WLZ < -2 Z-scores 2.5 [3;2] 2.25 [3.6;2] .653*
Wasting Severely Wasted 3 (1.8) 1 (0.8) .711**
(WLZ < 2 Z-scores) Wasted 7 (4.1) 3 (2.4)
Combined 10 (3.4) 4 (1.4)

Note: Values are expressed as count and percentage; IQR: Interquartile range.
LAZ ¼ Length-for-age z-score; WAZ ¼ Weight-for-age z-score; WLZ ¼ Weight-for-length Z-Score.* Mann-Whitney; **Chi-Square test.
In relation to the newer WHO standards, Moderate wasting (weight-for-length Z score, WLZ, < 2), severe wasting (WLZ < 3); underweight (WAZ < 2); severely un-
derweight (WAZ < 3.0); LAZ-scores generated using the 2006 World Health Organization (WHO) Growth Reference, were used to define stunting (LAZ < 2SD) and severe
stunting (LAZ < 3SD).

exclusive breastfeeding. statistically significant increase in breastfeeding among infants

The overall analysis revealed that several mothers were during the first hour following birth and maternal education
conscious of breastfeeding benefits. Analysis by educational (P < .001), as well as the economic level of the household (P < .001)
attainment and socio-economic status revealed that the percentage (Table 4).
of women with information on the benefits of the EB was signifi- Compared with the anthropometric indices of infants, our re-
cantly high among mothers with high and/or secondary education sults revealed a significant link between breastfeeding during the
and mothers with medium socio-economic status (Table 3). first hour following birth and the LAZ at the time of recruitment
(P < .001).
3.4. Sources of knowledge
3.7. Child feeding patterns
According to the interviews, 56.6% gained knowledge about
breastfeeding through their immediate family environment. Addi- At initial recruitment, 227 (76.4%) of infants were still being
tionally, 41.1% of the participants were provided with information breastfed, while 113 (38%) were bottle-fed. Breastfeeding was
on exclusive breastfeeding and useful steps for its successful common in the first six months (94.7%), with a significant pro-
management from health professionals. Mothers have clearly portion of women breastfeeding on demand (72.7%). The median
emphasized the relevance of informed counseling regarding number of feedings was four times daily. However, breastfeeding
breastfeeding received from health professionals. However, 22.2% did not last until the second half of childhood. Regarding the early
of mothers reported receiving information from television pro- introduction of food, we found that water was the most frequently
grams, radio and social networks. introduced element before the age of six months.
The proportion of infants who started mixed feeding at birth
3.5. Promoting breastfeeding among lactating mothers was 39.4%. The median age of onset of artificial feeding was two
months. 127 (42.8%) of the children were fed a formula for infants,
Many mothers reported that perceiving unconcerned behavior 64 (21.5%) of the infants were fed with cow's milk, 90 (30.3%) were
from health professionals and family members was linked breast- fed with first-age infant formula and 52 (17.5%) were fed with
feeding for a length of time far away from optimal guidelines. second-age infant formula. On the other hand, about two-thirds of
Grandmothers also provided assistance by way of babysitting to mothers (n ¼ 197) reported that a dummy had been given to their
help mothers return to work outside the home. baby in the first year to comfort the sick and crying child, while
However, the ability of fathers to help their wives was limited by other mothers reported the desire to satisfy the suckling reflex of
men's professional responsibilities. babies, and also as a mean of delaying the meals of infants.

3.6. Practices of breastfeeding during the first hour following birth 3.8. Exclusive breastfeeding practices and their correlation with the
socio-demographic characteristics of mothers and the nutritional
The majority of mothers gave breast milk to their infants during status of infants
the first hour following birth. A calculated 90.23% of mothers
breastfed their infants while 4.37% administered breast milk in a In our study, more than half of the mothers (57.23%) exclusively
bottle. The delayed onset of breastfeeding, ranging from a few breastfed their babies. The analysis, depicted in Table 5, exposed a
hours to several days, has been associated with various issues, greater percentage of exclusive breastfeeding among women with
including maternal or infant health problems. secondary or high education attainment in relation to illiterate
The study of this association between the different modalities of mothers and/or with a primary level of education, respectively
breast-feeding (breastfeeding, bottle-feeding and the use of infant (75.7% and/or 78.7% versus 3.7% and/or 3.6%; p < .001). On the other
formulas) and the socio-demographic characteristics of the mother hand, for mothers with an average economic level compared to
and the anthropometric parameters of infants highlighted a mothers with low household economic status, respectively with
 M. Habibi et al. / International Journal of Pediatrics and Adolescent Medicine 5 (2018) 39e48 43

Table 3
Mothers' knowledge of the benefits of breastfeeding: A comprehensive analysis and analysis by level of education and socio-economic status.

Breastfeeding Mother's Educational Status P value Mother's Economic Status P value Overall Analysis
Benefits
Illiterate Primary Secondary High Low Medium n ¼ 297
n ¼ 27 n ¼ 56 n ¼ 177 n ¼ 37 n ¼ 83 n ¼ 214

EB for about 6 months is the optimal feeding of infants .033*** .013***

Yes 24 (8.4) 52 (18.2) 173 (60.5) 37 (12.9) 76 (26.6) 210 (73.4) 286 (96.7)
No 3 (27.3) 4 (36.4) 4 (36.4) 0 (0) 7 (63.6) 4 (36.4) 11 (3.7)
EB protects against diseases, such as otitis media, acute diarrheal disease, .044*** .429**
lower respiratory illnesses
Yes 23 (8.3) 53 (19.1) 165 (59.4) 37 (13.3) 76 (27.3) 202 (72.7) 278 (93.6)
No 4 (21.1) 3 (15.8) 12 (63.2) 0 (0) 7 (36.8) 12 (63.2) 19 (6.4)
BF prevented a major portion of illness before the immunization against <.001*** <.001**
infectious diseases
Yes 11 (4.8) 24 (10.6) 157 (69.2) 35 (15.4) 35 (15.4) 192 (84.6) 227 (76.4)
No 16 (22.9) 32 (45.7) 20 (28.6) 2 (2.9) 48 (68.6) 22 (31.4) 70 (23 .6)
BF has been associated with a decrease in the risk for both breast and ovarian <.001*** <.001**
cancers
Yes 12 (5.1) 33 (14.1) 156 (66.7) 33 (14.1) 45 (19.2) 189 (80.8) 234 (78.8)
No 15 (23.8) 23 (36.5) 21 (33.3) 4 (6.3) 38 (60.3) 25 (39.7) 63 (21.2)
BF mothers have decreased postpartum blood loss and more rapid involution <.001** <.001**
of the uterus
Yes 11 (6.1) 23 (12.7) 120 (66.3) 27 (14.9) 34 (18.8) 147 (81.2) 181 (60.9)
No 16 (13.8) 33 (28.4) 57 (49.1) 10 (8.6) 49 (42.2) 67 (57.8) 116 (39.1)
Maternal-infant bonding is enhanced during BF .491*** .522**
Yes 22 (8.2) 51 (19.1) 160 (59.9) 34 (12.7) 73 (27.3) 194 (72.7) 267 (89.9)
No 5 (16.7) 5 (16.7) 17 (56.7) 3 (10) 10 (33.3) 20 (66.7) 30 (10.1)
BF results in reduced household expenditure for formula, as well as .784*** .520***
reductions in health care expenditures
Yes 26 (9.1) 55 (19.3) 169 (59.3) 35 (12.3) 81 (28.4) 204 (71.6) 285 (96)
No 1 (8.3) 1 (8.3) 8 (66.7) 2 (16.7) 2 (16.7) 10 (83.3) 12 (4)
Breast milk promotes long-term cognitive development <.001*** <.001***
Yes 9 (4.2) 21 (9.8) 153 (71.5) 31 (14.5) 30 (14) 184 (86) 214 (72 .1)
No 18 (21.7) 35 (42.2) 24 (28.9) 6 (7.2) 53 (63.9) 30 (36.1) 83 (27.9)
The variable composition of human milk provides nutrients specifically .002** .001**
adapted to the changing needs of the infant
Yes 14 (6.1) 39 (17) 145 (63.3) 31 (13.5) 53 (23.1) 176 (76.9) 229 (77.1)
No 13 (19.1) 17 (25) 32 (47.1) 6 (8.8) 30 (44.1) 38 (55.9) 68 (22.9)
Breast milk features are not found in infant formula <.001*** <.001**
Yes 3 (1.4) 9 (4.2) 167 (78.4) 34 (16) 12 (5.6) 201 (94.4) 213 (71.7)
No 24 (28.6) 47 (56) 10 (11.9) 3 (3.6) 71 (84.5) 13 (15.5) 84 (28.3)
Postpartum weight loss may be facilitated in BF women <.001*** <.001***
Yes 0 (0) 3 (2.1) 111 (77.6) 29 (20.3) 3 (2.1) 140 (97.9) 143 (48.1)
No 27 (17.5) 53 (34.4) 66 (42.9) 8 (5.2) 80 (51.9) 74 (48.1) 154 (51.9)

Note: Values are expressed as count and percentage; BF ¼ breastfeeding; EB ¼ exclusive breastfeeding.
**Chi-Square test; *** Fisher's test. p < .05 is considered to be significant.

78% versus 3.6%, P < .001. In contrast, breastfeeding and artificial illiterate-secondary (P < .001), illiterate-high (P < .001), primary-
breastfeeding were more prevalent among mothers with lower secondary (P < .001) and primary-high (P < .001) education level.
levels of education and/or economic status. However, no difference was assumed between the length of
Compared to the nutritional status of children based on growth breastfeeding and the illiteracy-secondary (P ¼ .964) and
indicators (weight, height and age), our results revealed a statisti- secondary-higher level (P ¼ .385) groups. Meanwhile, the length of
cally significant difference between the type of child feeding and exclusive breastfeeding was higher among mothers from an
the LAZ scores (P < .001), as well as with WAZ scores at recruitment average socio-economic class (P < .001). In contrast, the duration of
(P ¼ .005). Indeed, the LAZ and WAZ scores were normal among the EB was statistically similar between the different age groups of
majority of children who were exclusively breastfed. In addition, no nursing mothers (P ¼ .303).
relationship was found between mothers age and the method of
infant feeding (P ¼ .340).
3.9.2. Characteristics of infants
The non-parametric Kruskall-Wallis test, showed a statistically
3.9. Correlation of the breastfeeding length with the characteristics significant relationship between the exclusive breastfeeding dura-
of mothers and infants tion and LAZ scores (P < .001), along with WAZ scores (P ¼ .003).
Analysis by age group of infants revealed a significant link be-
3.9.1. Characteristics of mothers tween exclusive breastfeeding and the WLZ scores for children aged
The median length of breastfeeding was 5 months (IQR ¼ 0e5), 6e8 months (P ¼ .005), and between breastfeeding and WAZ among
with extremes ranging from 0 to 7 months. children aged 9e11 months (P ¼ .018). On the other hand, no sta-
The nonparametric Kruskall-Wallis test revealed a significant tistically significant relation was found with the WLZ scores for the
relationship between the length of breastfeeding and education children aged 9e11 months (P ¼ .303) and among the 12e24 months
levels, as well as the socio-economic status of mothers. Indeed, the group, along with the WAZ scores for the children aged 6e8 months
length of exclusive breastfeeding was higher among mothers better (P ¼ .297) and 12e24 months (P ¼ .052). For the LAZ, a statistically
educated (P < .001). A significant difference was found between the significant difference was found across all age groups (P < .001).
44 M. Habibi et al. / International Journal of Pediatrics and Adolescent Medicine 5 (2018) 39e48

Table 4
Association between initiation of the newborn feeding within the first hour of birth with the mother's socio-demographic characteristics and the infant's anthropometric
parameters at the time of recruitment.

Variables Starting Newborn Feeding Within the First Hour of Birth (n ¼ 297) P value

Exclusive Breastfeeding Putting Breast Milk in a Bottle Infant Formula Milk

(n ¼ 268) (n ¼ 13) (n ¼ 16)

Mother's Age Groups .475***

Less than 20 years 10 (90.9) 1 (9.1) 0 (0)
20 to 29 years 134 (91.8) 7 (4.8) 5 (3.4)
30 to 39 years 103 (88) 5 (4.3) 9 (7.7)
40 years and over 21 (91.3) 0 (0) 2 (8.7)
Mother's Education <.001***
Illiterate 20 (74.1) 3 (11.1) 4 (14.8)
Primary school 38 (67.9) 7 (12.5) 11 (19.6)
Secondary school 175 (98.9) 2 (1.1) 0 (0)
Higher education 35 (94.6) 1 (2.7) 1 (2.7)
Household Economic Level <.001***
Low 58 (69.9) 10 (12) 15 (18.1)
Medium 210 (98.1) 3 (1.4) 1 (0.5)
Nutritional Status: Classification Based on Growth Indicators (Z-Scores)
WLZ .128***
Normal range 146 (93) 4 (2.5) 7 (4.5)
Overweight 55 (84.6) 7 (10.8) 3 (4.6)
Risk overweight 55 (90.2) 1 (1.6) 5 (8.2)
Severely wasted 4 (100) 0 (0) 0 (0)
Wasted 8 (80) 1 (10) 1 (10)
LAZ <.001***
Normal range 210 (98.1) 3 (1.4) 1 (0.5)
Severely Stunted 26 (72.2) 7 (19.4) 3 (8.3)
Stunted 32 (68.1) 3 (6.4) 12 (25.5)
WAZ .108***
Normal range 248 (91.2) 10 (3.7) 14 (5.1)
Severely underweight 4 (80) 1 (20) 0 (0)
Underweight 16 (80) 2 (10) 2 (10)

Note: Values are expressed as count and percentage. LAZ ¼ Length-for-age z-score; WAZ ¼ Weight-for-age z-score; WLZ ¼ Weight-for-length z-score.
***Fisher's test. p < .05 is considered to be significant.
Referring to the WHO standards: Moderate wasting (weight-for-length Z score, WLZ, < 2), severe wasting (WLZ < 3); underweight (WAZ < 2); severely underweight
(WAZ < 3.0); Length-for-age Z-scores (LAZ), generated using the 2006 World Health Organization (WHO) Growth Reference, were used to define stunting (LAZ < 2 SD) and
severe stunting (LAZ < 3 SD).

3.10. Obstacles to exclusive breastfeeding environmental factors define whether an infant is breastfed or
formula-fed [28]. Human milk for human babies is unquestionably
During the interviews, 227 of the mothers (76.43%) reported the biological standard [2e4]. Studies in both industrialized and
that they planned to breastfeed their infants exclusively until the developing countries have assessed the short-term and long-term
age of 12 months. Among these women, 66% of mothers did not outcomes on infant and maternal health with respect to breast-
reach their intended breastfeeding duration for numerous reasons, feeding initiation [29].
including difficulties related to maternal health problems and the The World Health Organization (WHO) recommends exclusive
widespread belief among mothers that food and other liquids were breastfeeding without any additional food or water till 6 months of
more nutritious than exclusive breast milk. Additionally, many age. Subsequently, it is recommended to introduce complementary
mothers stated that they frequently suffered negative reactions to foods at six months and sustain breastfeeding until the age of 24
breastfeeding in public places due to the increased social tendency months [30].
to breast sexualization, which limited their breastfeeding ability. The threats of not breastfeeding are well established and
Table 6 summarizes the main constraints affecting the imple- encompass infections, malnutrition, deficiencies, and underdevel-
mentation of good breastfeeding practices. The overall analysis opment [31].
revealed that the majority of mothers did not report having diffi- In Morocco, the practice of breastfeeding remains deficient and
culties breastfeeding their child. Analysis comparing the level of unsatisfactory with regards to the goals recommended by the
education and socioeconomic status of mothers revealed a statis- WHO. Indeed, in the national surveys, the rate of exclusive
tically significant difference between the education level and so- breastfeeding of newborns at term at the age of six months was
cioeconomic categories concerning the short-term separation estimated at 27.8% in 2011 [13]. In premature children, this rate was
between the woman and her infant (P < .001). evaluated at 57.9% at the age of three months [32].
Furthermore, many women expressed feelings of guilt and Most of the available Moroccan studies have, in recent years,
anxiety about failure to meet their hypothetical expectations of expressed alarm at the observed decline in the practice and length
maternity due to the inability to overcome the challenges of of exclusive breastfeeding. Indeed, there is currently a tendency to
breastfeeding, particularly when there is pressure from their family regress this practice in relation to progress in the marketing of
environment. industrial milks and the lack of information and awareness of
mothers [33].
In the present study, almost 58.2% of infants (n ¼ 173) had been
4. Discussion
exclusively breastfed, which is well above the national average. The
median duration of exclusive breastfeeding for mothers was five
A multitude of social, psychological, emotional, and
 M. Habibi et al. / International Journal of Pediatrics and Adolescent Medicine 5 (2018) 39e48 45

Table 5
Association between the type of breastfeeding with mother's socio-demographic and infant's anthropometric parameters.

Variables Feeding Type (Since Birth) (n ¼ 297) P value

Exclusive Breastfeeding Artificial Feeding Mixed

(n ¼ 170) (n ¼ 8) Feeding
(n ¼ 119)

Mother's Age Group .340***

Less than 20years 9 (81.8) 0 (0) 2 (18.2)
20 to 29years 81 (55.5) 2 (1.4) 63 (43.2)
30 to 39 years 65 (55.5) 5 (4.3) 47 (40.2)
40 years and over 15 (65.2) 1 (4.3) 7 (30.4)
Mother's Education <.001***
Illiterate 1 (3.7) 1 (3.7) 25 (92.6)
Primary school 2 (3.6) 7 (12.5) 47 (83.9)
Secondary school 139 (78.7) 0 (0) 38 (21.5)
Higher education 28 (75.7) 0 (0) 9 (24.3)
Household Economic Level <.001***
Low 3 (3.6) 8 (9.6) 72 (86.7)
Medium 167 (78) 0 (0) 47 (22)
Mother's Professional Activity .102***
Housewife 151 (58.3) 5 (1.9) 103 (39.8)
Paid worker 19 (50) 3 (7.9) 16 (42.1)
Nutritional Status Classification Based on Growth Indicators (Z-scores)
WLZ .288***
Normal range 98 (62.4) 4 (2.5) 55 (35.0)
Overweight 28 (43.1) 3 (4.6) 34 (52.3)
Risk overweight 37 (60.7) 1 (1.6) 23 (37.7)
Severely wasted 2 (50) 0 (0) 2 (50)
Wasted 5 (50) 0 (0) 5 (50)
LAZ <.001***
Normal range 167 (78) 0 (0) 47 (42)
Severely Stunted 0 (0) 2 (5.6) 34 (94.4)
Stunted 3 (6.4) 6 (12.8) 38 (80.9)
WAZ .005***
Normal range 164 (60.3) 8 (2.9) 100 (36.8)
Severely underweight 1 (20) 0 (0) 4 (80)
Underweight 5 (25) 0 (0) 15 (75)

Note: Values are expressed as count and percentage. LAZ ¼ Length-for-age z-score; WAZ ¼ Weight-for-age z-score; WLZ ¼ Weight-for-length z-score.
***Fisher's test. p < .05 is considered to be significant.

Table 6
Correlation between reported barriers to exclusive breastfeeding with mothers' educational attainment and economic status.

Constraints Mother's Educational Status P value Mother's Economic Status P value Overall Analysis

Illiterate Primary Secondary High Low Medium n ¼ 297

n ¼ 27 n ¼ 56 n ¼ 177 n ¼ 37 n ¼ 83 n ¼ 214

Mastitis/Breast Abscess .361*** .340***

Yes 3 (7.7) 5 (12.8) 23 (59) 8 (20.5) 8 (20.5) 31 (79.5) 39 (13.1)
No 24 (9.3) 51 (19.8) 154 (59.7) 29 (11.2) 75 (29.1) 183 (70.9) 258 (86.9)
Full Breasts/Breast Engorgement/Sore or Fissured Nipple .371*** ,534**
Yes 2 (6.5) 5 (16.1) 17 (54.8) 7 (22.6) 7 (22.6) 24 (77.4) 31 (10.4)
No 25 (9.4) 51 (19.2) 160 (60.2) 30 (11.3) 76 (28.6) 190 (71.4) 266 (89; 6)
Perceived Insufficiency and Low Breast-Milk Production .199** .181**
Yes 10 (9.1) 26 (23.6) 65 (59.1) 9 (8.2) 36 (32.7) 74 (67.3) 110 (37)
No 17 (9.1) 30 (16) 112 (59.9) 28 (15) 47 (25.1) 140 (74.9) 187 (63)
Inverted, Flat, Large and Long Nipples .149*** .336***
Yes 2 (9.1) 2 (9.1) 12 (54.5) 6 (27.3) 4 (18.2) 18 (81.8) 22 (7.4)
No 25 (9.1) 54 (19.6) 165 (60) 31 (11.3) 79 (28.7) 196 (71.3) 275 (92.6)
Low Breast-Milk Intake .097*** .520***
Yes 2 (16.7) 0 (0) 7 (58.3) 3 (25) 2 (16.7) 10 (83.3) 12 (4)
No 25 (8.8) 56 (19.6) 170 (59.6) 34 (11.9) 81 (28.4) 204 (71.6) 285 (96)
Being Depressed, Lacking in Confidence, Worried, or Stressed .491*** .357**
Yes 2 (8) 7 (28) 12 (48) 4 (16) 9 (36) 16 (64) 25 (8.4)
No 25 (9.2) 49 (18) 165 (60.7) 33 (12.1) 74 (27.2) 198 (72.8) 272 (91.6)
Short-Term Separation Due to Employment Outside the Home <.001*** .001***
Yes 1 (12.5) 6 (75) 0 (0) 1 (12.5) 7 (87.5) 1 (12.5) 8 (2.7)
No 26 (9) 50 (17.3) 177 (61.2) 36 (12.5) 76 (26.3) 213 (73.7) 289 (97. 3)
Health Facility Environment and Family Members Were Not Supportive .210*** .527***
Yes 0 (0) 2 (15.4) 7 (53.8) 4 (30.8) 2 (15.4) 11 (84.6) 13 (4.4)
No 27 (9.5) 54 (19) 170 (59.9) 33 (11.6) 81 (28.5) 203 (71.5) 284 (95.6)

Note: Values are expressed as count and percentage. ** Chi-Square test; *** Fisher's test. p < .05 is considered to be significant.
46 M. Habibi et al. / International Journal of Pediatrics and Adolescent Medicine 5 (2018) 39e48

months (IQR: 5e6). and positive reinforcement, about breastfeeding from hospital staff,
Nevertheless, as stated formerly in literature [34], our study obstetricians, pediatricians, or other primary health care providers,
brings out that early complementary feeding is a widespread even after accounting for her own will and pressures presented by
misconception in the Moroccan population as a method for dealing immediate relatives. Indeed, physicians can take a more effective
with supposed maternal milk insufficiency. From the time that role in leading the management of breastfeeding as a driving force
public, social and cultural opinions alter women's decision, for mothers' decision-making, during and after the maternity.
educating and engaging the community as a whole is fundamental The current study further sheds light on the heavy caregivers'
to improve the duration of breastfeeding. influence exerted over the process of encouraging mothers to
Water was the elementary substance most often introduced breastfeed, and involving the impact on public health. This reflects
before the age of six months. Many mothers (n ¼ 162) commonly earlier work in Morocco, which emphasized that health outcomes
introduced a first combination of both vegetables and breast milk depend not entirely on the rate of access to health services, but also
during complementary feeding (54.5%). In other cases (n ¼ 73), on the quality of health care delivered [47].
commercial milk formula and dairy products had been supplied to On the other hand, many non-breastfeeding mothers felt that
the children (24.6%). Additionally, 17.5% of the mothers had chosen bottle-feeding by choice is a severe setback of their maternal
cereal products (n ¼ 52) or a variety of fruits (3.4%), as supple- function in the eyes of their community. Therefore, these mothers
mentary sources of dietary nutrients. It will be noted in this respect requested, from health professionals and family, more assistance
that experimental reviews of the effect of regularly exposing infants and guidance in their chosen approach, which is in line with the
to vegetables or fruits are positively ideal, with significant increases findings in other studies. Several reviews reported an association
in short-term compliance with the exposed food [35]. between decisions to formula feed and feelings of guilt, blame and
Nearly two-thirds of mothers (n ¼ 197) reported that a pacifier failure [48,49]. Health care workers must be aware that mothers
had been given to their infant for various reasons at some point who have to stop breastfeeding need to be understood to avoid a
during their baby's first year. risk of depression [49]. Instead, hiding key messages about formula
Let us point out that a huge number of studies have underlined a feeding to encourage breastfeeding could have harmful side-effects
correlation between shortened duration of exclusive breastfeeding on babies who do not get sufficient breast milk and infant formula
and the use of a pacifier [36,37]. In contrast, the Cochrane review, may be mistakenly prepared [50].
concerning use or disuse of a pacifier highlighted that there is no Moreover, it has been underscored in the literature [48], that
categorical proof that using a pacifier for infants decrease the moral reproach for a decision not to breastfeed for any reason is
breastfeeding duration [38]. inadequate. Health professionals should promote breastfeeding
Furthermore, in our investigation numerous nursing mothers, without morally belittling women who do not breastfeed.
especially those with higher levels of education, knew nutrition Our investigation showed that 66% of mothers did not reach
health outcomes of exclusive breastfeeding. This result is consistent their initial intended breastfeeding duration. Several mothers suf-
with the result of other studies that have reported a positive impact fered from health issues that were largely related to perceived
of education level on knowledge, attitudes, and support practices of insufficiency or hardships with breast milk production (full breasts,
exclusive breastfeeding [39]. breast engorgement, mastitis, etc.). Previous research has demon-
This growing maternal consciousness of the benefits of breast- strated that nipple pain while breastfeeding, was an absolute bar-
feeding in Morocco may be explained by the favorable effect over rier to exclusive breastfeeding for women [42,51,52] However, a key
the years of awareness-raising campaigns striving to promote the finding in the Cochrane review was that whatever the treatment
significance of exclusive breastfeeding in light of the strategies adopted nipple pain will decrease in 7e10 days after birth. This
targeted by the WHO and the UNICEF. Through these initiatives, information is relevant to provide to women as a way of dealing
thousands of women nationwide are benefiting annually from with their ache [51,52].
sensitization campaigns to incentivize the importance of breast- In our study, we also found a significant relationship between
feeding, as well as practical guidance on the essential steps for the the interruption of exclusive breastfeeding and separation due to
achievement of optimal breastfeeding [40]. mothers' employment conditions outside the home. This observa-
Furthermore, the duration of exclusive breastfeeding in our tion is in agreement with the results from other investigations [53],
study was significantly higher among mothers with an average which found that allowing mothers to stop working outside of the
socioeconomic level (P < .001). The socioeconomic status (SES) is house has a positive effect on breastfeeding. The most negative
already acknowledged as a variable influencing breastfeeding, with effect of employment on breastfeeding occurs during the first three
mothers in a higher income bracket breastfeeding longer, regard- months after birth [41,54].
less of race [41]. It is now generally established in the literature that the provi-
Contrary to theoretical expectations, mothers were not sion of mothers with appropriate means, to ensure compatibility
constantly able to individually meet the WHO guidelines despite between breastfeeding and working conditions, should be a na-
the positive efforts of health institutions, as has previously been tional priority [46]. Government initiatives and social policies can
emphasized by other reviews [42e44]. It is well established that provide further facilitative devices in order to help address the lack
communication gaps make a serious contribution to the frequent of substantial workplace accommodation for breastfeeding
discord between mothers' perceptions and clinicians' approaches mothers as well as requiring employers to create support for
to breastfeeding performance. Previous studies have unraveled lactation at work [41]. Breastfeeding women working in positions
current shortcomings in communication between mothers and that do not provide maternity leave or workplace support for
their doctors, which may adversely affect the exchange of relevant breastfeeding may find the strain too difficult to manage and
information and the strengthening of adherence to guidelines [44]. choose to wean their babies prematurely [55]. Further research is
Several women interviewed reported that a perceived lack of required to establish public health strategies to combine breast-
worry or interest from caregivers regarding the breastfeeding feeding and employment, emphasizing that pumping in the
practices was related to breastfeeding durations falling short of workplace can to breastfeeding benefits identical to those of direct
ideal guidelines. These findings are in accordance with earlier breastfeeding [56].
studies [45,46], that mothers are quite susceptible to messages they On the other hand, many surveyed mothers reported that they
receive implicitly and explicitly, such as encouragement, support, had been asked to cover themselves while breastfeeding in a public
 M. Habibi et al. / International Journal of Pediatrics and Adolescent Medicine 5 (2018) 39e48 47

area. The anxiety of breastfeeding publicly was noted as a reason for feeding relied primarily on the mother's memories.
some women choosing to bottle-feed. Some mothers reported that In that respect, setting up a prospective study, with a much
they are not at ease to breastfeed in the presence some relatives. larger sample, can put the results in wider perspective for scaling
Hence, whereas the public health consensus that breastfeeding is up breastfeeding interventions throughout the country.
crucial for child health and survival, reintroducing the normality of
breastfeeding in public places would be a positive step toward Ethical statement
reducing the perception that breastfeeding in public is a sexual
behavior [41,57,58]. Groleau et al. [58] brought this issue of the This research received prior approval from the Institutional
sexualization of breastfeeding to light in the Western world as a Ethics Committee of the Faculty of Medicine in Rabat, Mohamed V
barrier to adopting exclusive breastfeeding for women. University, Morocco.
Lastly, we examined the relationship between the type of The interview content was explained in detail to respondents.
breastfeeding and its association with the child's nutritional status. Free and informed verbal consent was obtained at the beginning of
We have demonstrated a statistically significant interaction be- each investigation from all participants.
tween the type of child feeding and the LAZ scores (P < .001), and Data collection and handling were done with strict confidenti-
WAZ scores at recruitment (P ¼ .005). A significant link was found ality. In addition, all participants were informed of their right to
between exclusive breastfeeding and WLZ scores for children aged withdraw their participation in the study at any stage.
6e8 months (P ¼ .005), and between breastfeeding and WAZ
among children aged 9e11 months (P ¼ .018). Disclosure
This result coincides with the findings of other studies, which
identified that children who were exclusively breastfed had This research did not receive any specific grant from funding
significantly higher weight gains, and extended exclusive breast- agencies in the public, commercial, or not-for-profit sectors.
feeding can improve the child's height and weight development
within the first few months [39,59]. Conflicts of interest
Many studies demonstrated that exclusive breastfeeding longer
than three months was positively correlated with childhood height. The authors declare that there are no conflicts of interests
Indeed, a study conducted in city of Jahrom in 2007 [60], concluded associated with this work.
that during the first few months of life, weight and height did not In addition, we confirm that this manuscript has been approved
vary between formula-fed and breast-fed infants, but in the sub- by all authors to be published in the International Journal of Pedi-
sequent period, breast-fed children gained more weight and height atrics and Adolescent Medicine and all of the copyright is trans-
than those who were formula-fed. In addition, several scientists ferred to the International Journal of Pediatrics and Adolescent
have expressed a positive association between exclusive breast- Medicine in case of acceptance.
feeding and growth in the period between 1 and 5e6 years [61,62].
However, other investigations demonstrated that formula-fed and Acknowledgements
breast-fed children did not differ in terms of growth [63].
In light of previous research, we also believe that an appropriate The authors would like to thank all the participants in the study
duration of breastfeeding, on the basis of expert recommendations, for their collaboration and insights.
is strongly recommended as the most affordable intervention that
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