Initiation, maintenance and continuation of exclusive breast feeding: Socio-demographic and maternal correlates for abandonment
Ogbondah B O
Abstract
Background: Exclusive breast feeding (EBF) has been shown to be an important and effective feeding practice essential for infant development. Initiation, maintenance and continuation of EBF were associated with several maternal and socio-demographic characteristics which influence EBF abandonment.
Methodology: The study is a prospective cross-sectional study conducted at the child health clinic in general hospital Bonny, in Bonny Island. The study population were nursing mothers of infants six months and below. All eligible nursing mothers that presented to the clinic were enlisted into the study until the required sample size was achieved. Study tool was a structured interviewer administered questionnaire. Multinomial regression analysis was done using SPSS with statistical significance set at 0.05.
Result: Results reveal significant statistical association between duration of EBF and some maternal variables such as parity, ante-natal attendance, breast feeding counselling, birth interval, gestational age and mode of delivery. Also, significant association was seen between duration of EBF and socio-demographic characteristics such as maternal occupation, income, education and marital status.
Conclusion: Abandonment of EBF before and its continuation up to six months can be influenced by socio-demographic factors such as maternal occupation, income and marital status. Other maternal variables which also influence EBF include ante-natal care attendance including the number of times of breast-feeding counselling, mode of delivery, gestational age, parity and birth interval.
Key words: Exclusive breast feeding, abandonment, initiation, maintenance, continuation.
Introduction
Breast feeding newborn was identified as the single most effective and affordable feeding practices necessary for development of healthy infants.1 Breast milk contains ideal source of nutrients and natural immunity for protection of infants against infections and chronic diseases and also for development of neurocognitive system.2 The human breast milk (HMB) contains several components including nutrients in a perfect combination.3 They also contain immune protective substances which help protect against neonatal infections and death.4 It is therefore imperative to place newborn on HBM soon after delivery as the colostrum which is rich in nutrients and immunoglobulins helps in priming the gastro-intestinal-tract thus reducing morbidity and mortality.5 Several benefits of breast feeding infants have been highlighted and includes reduced risk of otitis media, diarrhoea and other gastro-enteric diseases,6 reduced risk of stunting and wasting,7 decreased risk of rare diseases such as leukaemia, severe lower respiratory tract diseases and sudden infant death syndrome.8 Also, breast feeding helps prevent chronic diseases such as obesity,9 type 2 diabetes,10 and asthma.8
The benefits of breast-feeding abound and cannot be overemphasized. It is therefore important to develop programs and encourage research which will facilitate the promotion of breast-feeding. As important as breast feeding, even more important is engagement of nursing mothers in exclusive breast feeding (EBF). Exclusive breast feeding requires new born to receive only breast milk without any other food or drink including water except medicines prescribed by a doctor or nurse for six months of life.11 Many international initiatives such as “innocenti declaration” which is better known as “baby friendly hospital initiative” (BFHI) whose main objective is early initiation of breast-feeding with complementary feeds into second year of life,12 International code for the marketing of breast milk substitute,13 and implementation of ten steps towards successful breast-feeding14 amongst others have highlighted the importance of EBF. Most international organization such as the academy of medicine, the American academy of paediatrics and the Spanish association of paediatrics all recommend EBF for six months and complementary feeding for two years or more.15 Therefore, encouraging EBF and determining factors which could cause abandonment of EBF is critical if the world health organization global nutrition target for 2025 aimed at increasing EBF rate in first six months of life to at least 50% is to be achieved.16 Factors which could cause abandonment are multifactorial. The author identified three broad categories which included; (a) individual level; this includes biological factors such as cracked nipple, insufficient milk flow, psychological and personality trait of the nursing mother, (b) Environmental factors such as political commitment of the government e.g. government policy on infant feeding formular, cultural, religions and other geographical influences and (c) social factors including maternal education, maternal occupation, marital status, health care services e.g. antenatal care services etc. This study examined the effects of some of these social factors on abandonment of EBF before six months and continuation of EBF up to six months respectively. It has been documented that any amount of breast feeding is better than none with greater benefits if EBF is practiced for more than just six weeks or three months or mixed feeding.18 It is therefore imperative to identify some of these social factors which will encourage initiation, reduce abandonment and increase the duration of EBF by nursing mothers.
In Nigeria, the 2018 national demographic health survey reveals an EBF rate of 2.8 months with only 29% of infants exclusively breast fed.19 Suboptimal breast feeding in Nigeria is estimated to account for about 103,742 child deaths annually, translating to almost 12 billion dollars in future economic losses rising higher to 21 billion per year (4.1% of gross national income) if cognitive losses and health care cost are factored in.20
Nigeria is noted to have one of the highest rates of non EBF among infants aged 0-5 months despite introduction and implementation of various national and subnational initiatives to decrease non EBF among women.21 The initiation of breast feeding is increasing in Nigeria, however the duration and practice of EBF among women who had their babies delivered in a health facility and outside such facilities have remained low.22 In sub-Saharan Africa, prevalence of early initiation of breast-feeding ranges from 37.8% to 69.3% while prevalence of EBF ranges from 23.7% to 56.5%.23
Non EBF has remained the leading causes of death in most sub-Saharan African countries accounting for 45% of neonatal infectious death, 30% of diarrhoea and 18% of acute respiratory mortality among children under 5 years.24 In China, India, Nigeria, Mexico and Indonesia alone, suboptimal breast feeding accounted for over 236,000 annual child death with further economic cost and cognitive losses estimated at 119 billion dollars per year.25 To effect changes in present prevalence rate in terms of initiation and duration of EBF, there should be development, adoption and implementation of strategic initiatives aimed at policies which will reduce abandonment of EBF, enhance positive maternal attitude, improve on breast feeding counselling, strengthen the health care system and alter the present narrative to favour improved maternal education and economic empowerment of women.
The objective of the study is to determine socio-demographic and maternal variables which could influence initiation, abandonment and continuity of EBF at various stages of infant life up to six months after birth among nursing mothers.
Rationale for this study lies in the paucity of data on factors which influence abandonment of EBF at various stages of infant’s life up to six months after delivery and also to identify variables which could improve duration of EBF.
Material and method
The study is a prospective cross-sectional study conducted at the child health clinic in general hospital Bonny, in Bonny Island. The study population were nursing mothers of infants six months and below. Using the formular for determination of sample size for cross sectional studies,26 a sample size of 426 was derived after making adjustments for attrition. All eligible respondents that gave consent following explanation of study protocol were enlisted into the study on every child health clinic day which takes place on Tuesdays and Thursdays. Respondents were enlisted until the required sample size was achieved. Nursing mothers who refused consent and those with infants above six months were excluded from the study. This was to avoid recall bias. Data was collected using structured protested interviewer administered questionnaire, prepared in English language. Data elements included variables on maternal and socio demographic characteristics that could influence exclusive breast feeding. Data collected was cleaned and entered into excel spread sheet and then transported into statistical package for social sciences (SPSS) version 20.1. Analysis was done using multinomial regression analysis with level of statistical significance set at 0.05. Data was presented in simple frequency distribution table. Ethical approval was issued by the research and ethics committee of Rivers State hospital management board, while permission for the study was granted by the management of Rivers State hospital board.
Results
1.0 The mean maternal age was 30.06±6.12. The most predominant age grade among nursing mothers were women aged 15-30, 232(54.5%) while men aged 31-40 years where the most predominant amongst the spouses 255(59.8%). Table 1.
2.0. Socio-demographic characteristics and EBF duration
Multinomial regression analysis reveals significant association between EBF and socio-demographic variables such as maternal education, occupation, marital status spouse occupation and age.
3.0. Maternal variables and EBF duration
Multinomial regression analysis reveals significant association between EBF and maternal variables such as ANC attendance, number of ANC attendance, pregnancy intendedness, GA, parity, birth interval, breast feeding counselling and method of EBF.
4.0. Univariate logistic regression model showing EBF and socio-demographic characteristics
Univariate logistic regression analysis reveals 1-2 months of EBF as the critical period for abandonment of EBF by nursing mothers also, increasing maternal income was associated with increasing odds for abandonment of EBF
5.0. Univariate logistic regression model showing EBF and maternal variables
Univariate logistic regression analysis reveals maternal parity two and above associated with increasing odds for continuation of EBF up to 5-6 months also, mothers who had CS have high odds of abandonment of EBF at 1 – 2 months of infant life.
Discussion
The study identified significant association between initiation, abandonment and continuity of EBF with socio-demographic factors such as maternal occupation, income, education, marital status, spouse age and occupation. So also, were some maternal variables such as mode of delivery (MOD), gestational age (GA), parity, ante-natal-care (ANC) attendance, number of ANC attendance, pregnancy intendedness, breast-feeding counselling and method of EBF
Also, 138 (32.4%), 84 (19.7%), 48 (11.3%) and 156 (36.6%) of nursing mothers did not engage in EBF, discontinued EBF between 1-2 months, discontinued EBF between 3-4 months and exclusively breast-fed their infants up to 5-6 months respectively.
This study examined the most critical or vulnerable period of abandonment of EBF and did an appraisal of the odds for initiation, abandonment and continuation of EBF up to six months with reference to above mentioned socio-demographic and maternal factors.
The author identified three distinct period or phases during the first six months of EBF of an infant which includes period of initiation, maintenance and continuation corresponding to 1-2 months, 3-4 months and 5-6 months of period of EBF.
It was shown that, 156 (36.6%) of nursing mothers engaged in EBF up to 5-6 months of their infant’s life. This is high considering the global EBF rate of 15.2% and 21% at six months.24 However in Brazil, a high EBF rate of 68.4% was recorded at six months.27 In contrast, lower figures 5.5% and 18% were recorded in Italy and Ethiopia respectively.28,29 It has been documented that EBF rate could be multifactorial. Key social factor which might have influenced the high rate of EBF in this study could be high literacy rate of nursing mothers and their spouses. However, the influence of other factors which could also have had influence on EBF rate were not fully explored.
The critical point of abandonment of EBF by most nursing mothers was identified as the initiation phase (1-2 months) of EBF. It follows that, given all variables under study, most nursing mothers abandon EBF between the first two months of their infant’s life. This result corroborates the findings in other studies which identified second month of an infant’s life as the critical period for abandonment of EBF.29,30 In contrast, other studies revealed fourth month as the critical point of abandonment.31 The import of this finding is to identify, develop and implement programs proven to encourage EBF targeted at this vulnerable period with the ultimate aim of achieving greater EBF rate for infants. Therefore, further research should be encouraged on this frontier aimed at enhancing EBF at this critical point. Two factors which have shown strong positive influence in reducing abandonment during this critical period are high number of ANC attendance and maternal education up to secondary and tertiary level. These factors could be leveraged upon to circumvent abandonment at this period. Also, most nursing mothers result to infant formular following abandonment at this phase therefore, imposition of restriction by government on marketing infant formular milk and promoting breast feeding practices through mass media campaign,32 will greatly reduce the rate of abandonment at this point.
Abandonment of EBF have shown strong association with various maternal and socio-demographic factors. High maternal education up to secondary and tertiary level was associated with low odds for abandonment at initiation and maintenance phase with higher odds of continuation of EBF up to 5-6 months. This finding was corroborated in other studies which revealed a low prevalence and abandonment prevalence ratio, with high level of maternal education.31,33 It is believed that highly educated nursing mothers would appreciate the benefits of EBF following academic and educational exposures and would not be encumbered with the myths associated with EBF as seen in poorly educated nursing mothers.
Married nursing mothers showed remarkable low odds of abandonment of EBF both at initiation and maintenance phase with greater chances of EBF up to continuation phase. Some studies also concur with the result expressed in this study.30 It is believed that the spouse serves to motivate and encourage the nursing mother, providing assistance needed to practice EBF up until six months. It is therefore the opinion of the author that communities and the society be encouraged to promote matrimony and place a high premium on it, at least for the purpose of encouraging EBF and its attendant benefits.
Elective and emergency caesarean section (CS) was associated with higher chances of abandonment at the initiation phase. This was similar to a South American study.31 Expectedly, women who had CS may not initiate EBF and worse still may abandon it at the initiation phase, due to complications of surgery. Some studies corroborate this finding in which it states that mode of delivery was the strongest determinant of initiation and continuation of EBF.33 Therefore efforts should be targeted at initiation phase for nursing mothers who delivered via CS to improve EBF at this point. Some measures which could assist in this regard include infection control and improved surgical procedure to decrease post surgical morbidity which greatly contribute to inability to initiate EBF or even abandonment at the initiation phase.
Gestational age (GA) 28 weeks and below have higher chances of engaging in EBF up to continuation phase with low odds of abandonment at initiation and maintenance phase. Study by Machado MCM et al was in tandem with this result.31 However some studies do not concur.36 Nursing mothers who delivered at GA of 28 weeks and below are more anxious over the welfare of their newborn and will comply with the advice of health care workers (HCW) to exclusively breast feed up to six months. It is expedient therefore to continuously engage these group of women on the need for EBF and to sustain the gains already achieved. Most importantly, more effort should be targeted at other groups with GA above 28 weeks.
Odds for abandonment increases with increasing maternal income at the initiation phase, similarly, increasing maternal income was associated with decreasing odds for EBF up to continuation phase. This result was similar to the result seen in a study in Poland.34 Expectedly increasing maternal income is associated with greater economic and physical engagement which might disrupt EBF. Therefore, special program targeted at initiation and continuation phase should be designed for working class women to improve EBF rate. Therefore, nursing mothers who are engaged with any economic activity should have a baby friendly working environment. This may require policies which will encourage baby friendly working environment and also flexible working hours to encourage these women to sustain EBF.
Birth interval two years and above was statistically associated with EBF up to continuation phase. Most remarkable was a significant improvement in EBF at maintenance phase following increase in birth order from one to two years. This result was corroborated by a study in Ethiopia giving credence to increased EBF rate following birth interval two years and above.35 Therefore, encouraging women to practice birth spacing of at least two years via modern family planning method will enhance rate of EBF.
Attending ANC clinic with its attendant breast-feeding counselling greatly encourages EBF up to continuation phase and subsequently reduces abandonment especially at the maintenance phase. Interesting to note that odds for abandonment decreases with increasing number of breast-feeding cancelling. Other studies found credence with our results.36 Encouraging women to register for ANC with its corresponding number of breast-feeding counselling have been shown to be a cost-effective measure towards increasing rate of EBF and subsequent reduction in abandonment of EBF.
Parity was shown to be associated with EBF in which increasing maternal parity two and above was significantly associated with EBF up to continuation phase and also a significant low odd for abandonment at maintenance phase. There have been divergent views among scholars on this issue. While some scholars agree with our results31,34 some others disagree.36 With credence to the result obtained in this study, logical reasoning would indict inexperience and anxiety for poor practice of EBF in nulliparous and women with single parity. Therefore, efforts and programs should be targeted at this group to enhance EBF up to continuation phase and reduce rate of abandonment.
However, the results obtained in this study have limitations in that, individual and environmental factors which also might affect abandonment of EBF and its sustainability to the phase of continuation was not fully investigated. It therefore reasons that, the factors discussed above will suffice if they acted alone or in which individual and environmental factors do not play significant role. The author therefore encourages research into the multifactorial nature of variables influencing EBF.
Conclusions
Abandonment of EBF before and its continuation up to six months can be influenced by socio-demographic factors such as maternal occupation, income and marital status. Other maternal variables which also influence EBF include ANC attendance including the number of times of breast-feeding counselling, MOD, GA, parity and birth interval.
References