EFEECT OF NURSING- BASED INTERVENTION ON EXCLUSIVE BREASTFEEDING PRACTICE AMONG PREGNANT WOMEN ATTENDING TWO PRIMARY HEALTH CARE CENTERS
CHAPTER TWO
LITERATURE REVIEW
2.1 BREASTFEEDING
Breastfeeding has been reported as an age-old practice that has been very critical not only to the physiology, growth, and overall well-being of neonates but the physiology and health of women as well.
Indeed, scarcely does a society exist without some form of infant breastfeeding; for it is one of the practices among human societies that transcend the boundaries of time and place. The practice has been a method of feeding to which infants have not only adapted but lived on for most of human existence on earth.
2.2 BENEFITS OF BREASTFEEDING
There is consistent evidence of short-term benefits and potential long-term benefits in breastfed infants. In addition, benefits of breastfeeding to maternal health, as well as advantages for health care systems and society, have been described.
2.2.1 FOR INFANTS
The components of breast milk exert dual roles; one is to provide nutrition and another is to encourage immunity and development.
Breast milk changes its composition from colostrum to mature milk to meet the different stages of nutrition needs from newborns to older infants.
It provides the required nutrients in easily digestible and bio available forms. 10
Breast milk also contains a wide variety of living components including antibodies, enzymes and hormones.9
The health benefits of breast milk cannot be replaced by formula milk. Bioactive factors such as human secretory immunoglobulin A (sIgA), lactoferrin, lysozyme, oligosaccharides, growth factors and cellular components may benefit infant’s host defence system. 11
There is convincing evidence that breastfeeding reduces infant mortality and decreases the risk of acute illnesses such as gastrointestinal infections, lower respiratory tract diseases and acute otitis media. 12
In developing countries, breastfeeding is a life-or-death issue. A meta-analysis showed significant protective effects of breastfeeding.13 The paper found that infants who were not breastfed had a risk of dying from infectious diseases in the first month of life six folds greater than those who were breastfed.13 Significant reduction in the risks of gastrointestinal infections, lower respiratory tract diseases and acute otitis media were also observed in developed countries that can be directly attributed to breastfeeding. 12
In addition, a systematic review concluded that breastfeeding is associated with lower rates of childhood obesity, certain allergic conditions, type 2 diabetes and leukemia.12
There are some other potential long-term benefits of breastfeeding for infants:
such as higher cognitive outcome in full-term infants
less cardiovascular mortality in adults and lower adult blood pressure.12
2.2.2 FOR THE MOTHER
Breastfeeding is also beneficial for mothers, including decreased risks of:
Type 2 diabetes,
Breast cancer 14, ovarian cancer15 and
Maternal postpartum depression.16-18
A study of two large cohorts including 150,000 parous female nurses in the United States19 found that, without a history of gestational diabetes, each additional year of breastfeeding was associated with a 4% reduction in the risk of developing type 2 diabetes in the first cohort and a 12% reduction in the risk in the second cohort.
There is good evidence from the latest meta-analyses to support that breastfeeding is associated with a reduction in the risk of breast cancer. A collaborative reanalysis study including more than 50,000 women with breast cancer and more than 90,000 controls, examined individual data from 47 studies and found that the relative risk of breast cancer decreased by 4.3% for every 12 months of breastfeeding, in addition to a decrease of 7% for each birth.14
The Agency for Healthcare Research and Quality 12 reviewed 9 case-control studies and concluded that there was an association between breastfeeding and a 21% (95% CI: 9%, 32%) reduction in the risk of ovarian cancer, compared to never breastfeeding.
2.2.3 FOR SOCIETY
In addition to the specific health advantages for infants and mothers, breastfeeding also benefits society by:
Reducing health care costs, parental employee absenteeism and associated loss of family income.20
As breastfeeding benefits the health of infants and mothers, it decreases the cost to families, employers, society and health care systems by reducing the costs of buying infant formula, parental employee absenteeism and the expenses of medical care (duration of hospitalization, health service use).20
A study in the United States estimated that if 50% of infants were exclusively breastfed for the first three months of life, approximately $4 million per month would be saved.21
Several studies have been carried out to ascertain the level of knowledge, attitude and practice of exclusive breast feeding.
Similarly, in the same vein, studies have been done in the past to measure infant anthropometric status and also show the relationship between exclusive breast feeding and infant body size measurement (anthropometry).
2.3 EXCLUSIVE BRESTFEEDING
Infants were considered exclusively breastfed if they received no breast milk substitutes (other than vitamins or medications) and were considered non-exclusively breastfed if they were supplemented with water, infant-formula and/or other breast milk substitutes.22
Exclusive breastfeeding has been recognised as an important public health tool for the primary prevention of child morbidity and mortality. Consequently, the WHO and UNICEF have recommended exclusive breastfeeding for the first six months after delivery, followed by introduction of complementary foods and continued breastfeeding for 24 months or more.
2.4 DEFINITION OF KNOWLEDGE, ATTITUDE AND PRACTICE (KAP)
“KAP” study measures the Knowledge, Attitude and Practices of a community. It serves as an educational diagnosis of the community.23 KAP Study tells us what people know about certain things, how they feel and also how they behave.
Knowledge: Knowledge is the capacity to acquire, retain and use information; a mixture of comprehension, experience, discernment and skill.24
It is a set of understandings. It is also one’s capacity for imagining, one’s way of perceiving.25 Knowledge of a health behaviour considered to be beneficial, however, does not automatically mean that this behaviour will be followed. The degree of knowledge assessed by a survey helps to locate areas where information and education efforts remain to be exerted.
Attitude: Attitude refers to inclinations to react in a certain way to certain situation; to see and interpret events according to certain predispositions; or to organize opinions into coherent and interrelated structure.24
It is also a way of being, a position. These are leanings or “tendencies to….”. This is an intermediate variable between the situation and the response to this situation. 25
Attitudes are not directly observable as are practices, thus it is a good idea to assess them. It is interesting to note that numerous studies have often shown a low and sometimes no connection between attitude and practices.
Practice By Practice we mean the application of rules and knowledge that leads to action.23 Good practice is an art that is linked to the progress of knowledge and technology and is executed in an ethical manner.
Practices or behaviours are the observable actions of an individual in response to a stimulus. This is something that deals with the concrete, with actions.24
Understanding the levels of Knowledge, Attitude and Practice will enable a more efficient process of awareness creation as it will allow the program to be tailored more appropriately to the needs of the community.23
2.5 KNOWLEDGE OF EXCLUSIVE BREAST FEEDING
Knowledge is a powerful tool to practice; several studies have shown that one of the key areas of information dissemination as regarding breast feeding is the ante-natal and post-natal clinics.
Given that one of the main goals of ante-natal and post-natal clinics is to broaden the knowledge of expectant and nursing mothers.
Several studies have been done to assess the levels of knowledge of exclusive breast feeding.
Tuan et al26 in their study in Chililab, Vietnam, showed that 51.1% of the participants had high level of knowledge about exclusive breastfeeding. This proportion is lower compared with the result of a study in Ho Chi Minh City, Vietnam27 which had a level of 94.1% and also lower than the result of a study in Jamaica with 98%.28
Also, an important finding in their study was the proportion of participants who had ever seen advertisement about formula milk on television which was 92.8%.26
This is because of the study was performed in Chilalab where almost households had at least one television, and there were many advertisements about formula milk on television per day in
Vietnam, and the policy in Vietnam permit advertisement formula milk on television. This finding intended consistent with the result of study in Laos, a neighboring country of Vietnam29.
Education has been pointed as a key factor in enhancing knowledge as well as practice by most studies on KAP on exclusive breast feeding.
Tan KL30 in his work on exclusive breast feeding in Klang, Malaysia showed that 71% of respondents reported that ‘Breast milk is the best for the infant’. Baby friendly hospital initiative and promotion of breastfeeding in health clinics that emphasize the advantages of breast milk over infant formula milk were probably the reason in maintaining this practice.
An important factor to note was that their respondents were selected from the government health clinics only. Malaysian women reported that health care workers encouraged breastfeeding but not the community. In Malaysia, breastfeeding in public places is viewed as a taboo due to the actual or gesture of exposing the breast.30 Education and awareness must be imparted to the community regarding breastfeeding to eliminate the hostility among the community on women who needed to breastfeeding in public places.
A study conducted on lactating mothers in Bedelle Town, South-western Ethiopia by Tsedeke et al 31 showed that all the mothers 220 (100%) knew the importance of breast feeding/EBF and 202 (91.8%) reported that breast milk alone is important for new born infant. 200 (90.9%) mothers reported that frequent breast feeding is needed for infants less than 6 months.
Their study revealed high knowledge of EBF. This might be due to the expansion of health infrastructures, increasing number of health personnel, community mobilization and health education given at large.
A similar study on urban refugee in Kigali, Rwanda by Bahemuka et al32 revealed that the majority (74.4%) of the urban refugee women involved in the study had correct knowledge about EBF, knowledge that they mainly acquired from health facilities.
This level of EBF knowledge, in comparison with same knowledge rates in different communities in the world may be considered satisfactory. As an illustration, one of the poorest levels of knowledge regarding EBF (3.2%) was revealed by a study conducted on Pakistani women33.
A study conducted in Mbarara Hospital, in the Republic of Uganda in 2003, showed that EBF knowledge level among the women was 73.8%, which is rather closer to findings their study34.
In Nigeria, several studies have demonstrated varied rates of knowledge of exclusive breast feeding. It has been shown that mothers with good knowledge of exclusive breastfeeding are more likely to breastfeed their infants exclusively in the first six months of life.35-42
Oliemen P et al43 in their study in Gbarantoru community of Bayelsa State showed that 59.7% of the mothers knew the correct definition and duration of exclusive breast feeding.
This was similar to the 50% knowledge reported by Okolie U44 in Enugu.
Ukaegbu et al45 however reported a higher knowledge of 91.2% among mothers attending the immunization clinic of the Nnamdi Azikiwe University Teaching Hospital, Nigeria.
This difference may be due to the fact that Ukaegbu’s study populations were urban dwellers whereas the population in Oliemen’s study was rural dwellers.
It has been demonstrated that women living in urban areas have better knowledge of exclusive breast feeding compared to women in rural areas.46, 47
The 59.7% knowledge of exclusive breastfeeding in Oliemen’s study is higher than 35.3% reported by Abdul Ameer et al48 in Iraq. The reason for this difference is not immediately clear but may be due to geographical and cultural differences between the two study populations.
The major source of information on exclusive breast feeding to the mothers in their study was health workers. This is similar to reports by Ukaegbu et al47 and El-Kariri and Kanoa.49
Oliemen et al43 study also revealed that apart from health workers, 10.4% of the mothers heard about exclusive breastfeeding from the television or radio. This highlights the importance of using the mass media as an alternative means of disseminating health information since about 46.8% of Nigerian mothers deliver outside health facilities50 and as such, may not have the privilege of getting infant feeding information from health workers.
In Columbia, the use of mass media was assessed as being more effective in reaching pregnant women and breastfeeding mothers than health and educational agents.51
Gupta et al52 carried out a study in Uganda on evaluation of the extent to which exposure to communication messages in the media on behavioral change determined recent improvement in exclusive breastfeeding knowledge. Their reports indicated that exposure to these messages was strongly associated with women’s knowledge of six months as the ideal duration for exclusive breast feeding. Positive influences on knowledge of men were also reported.
The fact that almost half of Nigerian mothers deliver outside health facilities also highlights the need for community awareness programmes on exclusive breastfeeding which was demonstrated
It has been shown that the key to successful breastfeeding is based on information, education and communication strategies aimed at behavior change53 with improved health care practices standing out as being the most promising means of reinforcing the prevalence and duration of breast feeding.54
Though Health workers knowledge and attitude have been identified as a major factor influencing exclusive breastfeeding rates in some communities, 55-57 there are concerns about health workers actually giving the mothers correct exclusive breast feeding information.
Okolo and Ogbonna58 carried out a study to assess the knowledge, attitude and practice of health workers towards baby friendly hospital initiative in Keffi Local Government area of Nigeria. They reported a low level of knowledge with 80.8% of them believing that babies less than 6 months on breast milk should also be given water.
Benjamin59 in Washington, USA also opined that health workers including doctors and nurses have surprisingly little training in lactation and lactation support. Schanler et al60 carried out a study on the educational needs of paediatricians in the United States regarding breastfeeding. They reported that exclusive breastfeeding for the first month of life was recommended by 65% of the paediatricians. The majority of the paediatricians had not attended any presentation on breast feeding management in the preceding three years and most of them wanted more education on breast feeding management.
The fact that almost half of Nigerian mothers deliver outside health facilities also highlights the need for community awareness programmes on exclusive breastfeeding which was demonstrated to increase knowledge of exclusive breastfeeding from 67.1% to 89.5% in a study done in fourteen Angawari centres in Chandigarh India.61
This low level of knowledge among mothers in Keffi LGA could be attributed to the fact of how informed health workers are about EBF. Health workers who are not well informed about EBF will most likely not pass sound information to mothers. This was opined by Benjamin59 in his work.
Another study to assess knowledge and practice of exclusive breast feeding in University of Uyo Teaching Hospital by Aneikan M et al62 showed that only 40% of the respondents were able to define EBF correctly. This rate is low when compared to findings from researches conducted in other parts of the country. A cross sectional study from Jos, North Central Nigeria63 revealedthat 82.3% of the study population was able to define EBF, while a study conducted in Enugu, Nigeria64 showed that 94% of the study population was able to define EBF correctly.
The low rate of knowledge of EBF in the University of Uyo Teaching Hospital is surprising since about three quarters of the women in their study had attained tertiary level of education. In addition, the meaning and need for EBF was discussed by midwives during booking and also at every antenatal visit. EBF was also discussed at the pediatric clinics, the immunization centre and also during the postnatal clinics.
Hence, the content of the health talks and the understanding of the messages by the women require evaluation as previous studies have shown significant gaps in knowledge of EBF among health care workers. Their study also showed the very poor contribution other vehicles of health information like the electronic and print media play in disseminating relevant and accurate health information about EBF to members of the public.
In the appraisal of nursing mother’s knowledge and practice of exclusive breast feeding in Yobe State, Ajibuah BJ 65 showed that 78.4% had not heard about exclusive breastfeeding. Of the 21.6% of mothers who had heard about EBF, 64.5% said they obtained such information from health workers, 9% from the media and 7.3% from their husbands.
Also, out of the 21.6 % who said they were aware of EBF, only about 27% could give the correct definition of EBF. More than half (52.8%) could not properly position their children while, 58.4% gave incorrect explanation of the child being properly attached to the breast. The following were identified by the mothers as benefits of breast milk: it is safe (21.9%), it is food (19%), it helps bonding (18.2%), and it helps on prevention of disease (17.5%).
This low level of knowledge in Yobe state could be attributed to the fact that this state or region is currently under the siege of unmitigated Boko haram that believes western education is a taboo. The beginning of Boko Haram ravaging in year 2008 was highly politicised hence, it was not nipped from bud now has become a dreaded monster devastating all the strata of socio- economic cum political development of the area.
Other studies in Nigeria carried out to assess knowledge rates of EBF include: Oche et al reported 31% in Kware; Maduforo et al67 in Owerri reported 90.6%.
2.6 ATTITUDE TO EXCLUSIVE BREAST FEEDING
Attitudes are not directly observable as are practices, thus it is a good idea to assess them. An indifferent attitude or apathy will most likely not result to practice, whereas a good attitude may or may not necessarily lead to practice.
Breastfeeding attitude refers to the level of mother’s positive or negative beliefs regarding EBF and the outcome evaluation of these beliefs68.
Several studies have been done to assess the levels of attitude towards EBF.
In Chililab Vietnam, Tuan et al26 showed that participants had roughly same rate; positive attitude (20.2%) and negative attitude (26.5%). Their study also showed that in Chilalab , almost all households had at least one television, and there were many advertisements about formula milk on television per day in Vietnam, and the policy in Vietnam permit advertisement formula milk on television.
Lack of emphasis on benefits of EBF in Chilalab may have accounted for the same rate of attitude.
Tsedeke et al31 in Bedelle Town, Ethiopia, showed that majority of mothers 192 (87.3%) had good attitude and strongly agreed that the EBF is advantageous for infants aged less than 6 months.36
Enhanced communication of content of health talks and emphasis on the benefits of EBF may have accounted for this high positive rate for EBF
A study conducted in Mbarara Hospital, in the Republic of Uganda in 2003, showed that the majority (71.1%) of the urban refugee women had a positive attitude towards EBF to 6 months34. This high level of attitude may be attributed to the fact that the benefits of EBF were strongly emphasised to mothers. This shows that strong emphasis on EBF can boost the confidence level of mothers. In addition to strong emphasis, another factor that may have accounted for the high
level was that EBF was properly communicated to the mothers putting into cognisance the educational level of the mothers as opposed to the roughly same rate of attitude to EBF in Chililab.26
This shows that emphasis on benefits of EBF and proper communication of EBF is pivotal for having good and positive attitudes.
In Nigeria, Zainab O et al69 in their study in Agbowo community, Ibadan, reported that respondents had roughly same attitude. Attitudes which were favourable to breastfeeding included: Breastfeeding increases mother-infant bonding (66.4%) Breastfed babies are healthier than formula fed babies (25.0%); Breast milk is cheaper than formula (21.6%) and Benefits of EBF last till adulthood (12.9%). Most of the respondents (31.9%) agreed that breast feeding makes mothers breasts sag while most of them felt it would be embarrassing to breastfeed in public spaces like banks and churches but not at home. The Mean attitude score in their study was 52.7%.
This same level of attitude could be attributed to the manner EBF was communicated to the respondents. Hence, there is need for emphasis on benefits of EBF and evaluation of content of health talks.
Ajibuah BJ 65 in his study in Yobe state showed that the proportion of respondents that had unfavourable attitude were more in the rural communities than in the urban communities. Also, a general pattern was noted as more people from urban areas delivered at health facility compared to people from rural areas who delivered at home.
The reason why urban people delivered at health facilities could be as a result of the fact that better health facilities and information are concentrated more in the urban areas than those in the rural areas, where such were not provided adequately. Access to quality information and treatment impacts a positive attitude to EBF.
2.7 PRACTICE OF EXCLUSIVE BREAST FEEDING
Tan KL30 in his work on exclusive breast feeding in Klang, Malaysia showed that 32.8% of the respondents exclusively breastfed for six months. This rate was higher than those reported in Malaysia Third National Health and Morbidity Survey 20065 and in the USA for the same ages70 but less than those reported in Eastern countries.71, 72
His study showed that factors associated with not practicing exclusive breastfeeding were mothers’ ethnicity, working status, household income and infant gender.
In Malaysia, health services are provided by both government and private hospitals. Hospitals and work places without facilities for breastfeeding can be detrimental for breastfeeding.
Cohen et al showed that women employed by businesses that are ‘breastfeeding friendly’ were able to maintain a breastfeeding regimen for at least six months at rates comparable to the rate of women who were not employed outside home.73 Ong et al showed that inadequate facility for breastfeeding at work place significantly reduces the duration of breastfeeding among working mothers.74
In Malaysia, women employed in the government sector were given two months maternity leave while for private sector the leave could range from two weeks to two months. Government policies regarding longer maternity leave both for government and private sectors should be considered. The respondent in his study were not satisfied with the length of their maternity
leave and they did not think that workplaces provided the right environment for successful breastfeeding.
Tuan et al26 in Chilalab showed that practice of exclusive breastfeeding was only 29%. This can be attributed to the fact that in their study, the proportion of participants who had ever seen advertisement about formula milk on television was 92.8%.26
Ampierie IP34 in Mbarara Hospital, Uganda, showed that although the participants in his study had enough knowledge about and good attitudes towards EBF, their practice of it was very low: only 34.4% of them practiced EBF to 6 months. The reason for the low practice was not reported in the study.
Several studies on practice in Nigeria show varying rates. Maduforo et al75 in Owerri reported a much higher exclusive breastfeeding practice rate of 66.4% among lactating women in Owerri Metropolis. Their higher exclusive breast feeding rate may be due to the fact that they also had a higher exclusive breast feeding knowledge of 90.6% as compared to the 59.7% found in Oliemen P et al43 study. According to Bryne et al76 mothers knowledge of exclusive breast feeding, determines their practice.
Some constraints to practice in their study were identified to be responsible included; lack of time, lack of knowledge, lack of support from the husband and family members and some do not believe that only breast milk is enough to sustain their baby of less than 6 months as well as many other excuses.
Aneikan M et al62 in University of Uyo Teaching Hospital, Akwaibom State revealed that 44.5% of the women had practiced EBF as recommended. This rate is however higher than the figures from the latest Nigerian Demographic and Health Survey5 and also slightly higher than the rates observed from other Nigerian studies and indeed studies from other developing countries. 77-81 Good and positive attitude towards EBF may have accounted for this rate. In addition, the size of family although not investigated in their study may have contributed to the high EBF rate, as the smaller the family size, the greater the chances of practice of EBF and vice versa.
Ajibuah BJ65 study on practice revealed that 15.3% practiced EBF. Family size was attributed as part of the low rate. Smaller family size had a positive effect on EBF among women with ≤ 3 children per family, who achieved higher EBF rates than those with ≥5.
Being a pre-dominantly Islamic state where polygamy is the norm, chances are so high that family size is also large.
Oche et al82 in Kware, Sokoto state reported that out of the 179 mothers, only 55(31%) practiced exclusive breastfeeding. The ages, education and occupation of the respondents were found not to have influenced the practice of EBF.
This figure is higher than the figures from the latest Nigerian Demographic and Health Survey5. An extended maternity leave and spousal support may have accounted for this rate.
2.8 EXCLUSIVE BREASTFEEDING TRENDS IN THE DEVELOPING WORLD
In recognition of the essential role of exclusive breastfeeding vis-à-vis infants’ survival strategies, a lot of effort has gone into scaling up the rates in developing countries where incidence of child malnutrition and mortality is still high. Yet, successes in increasing the levels of EBF have rather been modest.
In an analysis of data on EBF from 38 developing countries between 1990 and 2000, Labook 83 reported an increase EBF rate from 46% to 53% among infants younger than 4 months and from 34% to 39% for those younger than 6 months. Higher increment was noted in urban areas (30% to 46%) than rural ones (42% to 48%).
Although there were increases in all the regions studied viz. Middle East/ North Africa (29% to 34%), South Asia (49% to 56%), East Asia/Pacific (57% to 65%); the most impressive increment, however, was found in Sub Sahara Africa where the rate nearly doubled from 18% in 1990 to 38% in 200083.
Recent analysis by Cai et al84on the global prevalence of EBF across 140 countries, also reported an increase in the developing world from 33% in 1995 to 39% in 2010 among infants aged 0 ˗ 5 months. Increases from West and Central Africa were more than two-fold that is from 12% in 1995 to 28% in 2010.
There had also been considerable improvements from 35% in 1995 to 47% in 2010 among countries in Eastern and Southern Africa whereas those in South Asia witnessed a modest surge from 40% in 1995 to 45% in 2010.
Though it is still lower than the other regions, the rapid increase in West and Central Africa is probably not a surprise since it hitherto had and continues to have one of the lowest rates of EBF in the developing world for which reason intensive efforts were made to scale up the practice in the last two decades.
Although the rates of EBF for the past two decades have been increasing, it is certainly clear nevertheless that the road to a world wherein 90% coverage of EBF will be reached remains a demanding task. This is evident in the current low prevalence in much of the developing world especially in West and Central Africa which happens to have one of the highest rates of malnutrition in the world.85
While causal declarations about the modest successes that have been achieved throughout the 1990s and early part of the 21st century are quite difficult to make, some85 however, have linked the observed improvements in EBF rates to the efficacies of global and national policy efforts in the 1980s e.g. International Code of Marketing of Breast milk Substitute, and Baby and Hospital Friendly Initiative etc.
2.9 FACTORS AFFECTING EXCLUSIVE BREASTFEEDING
Previous research has documented numerous factors affecting practice of exclusive breast feeding. Based on documented research, the factors affecting the practice of EBF can be summarized thus:
1.Socio- demographic factors: Age, Level of education, Religion
2.Socio-economic factor: Income
3.Socio-cultural factors: Spousal support, Influence of in-laws and family size
4.Cultural practices
5.Beliefs
6.Mode of delivery
7.Health of mother
8.Work place environment
2.9.1 SOCIAL DEMOGRAPHIC FACTORS AFFECTING PRACTICE OF EBF
a)Age
The prevalence of exclusive breastfeeding declined with increasing infant age, from 68.0% at less than one month to 24.9% at five months. Vishnu K et al86 demonstrated this in Timor-Leste.
According to their local culture, it is common that Timorese infants are introduced complementary foods at about the 4th month. The decision is usually made by the senior women of the family such as the grandmother or grandmother-in-law.
Most research work have documented that mothers within the ages of 21-30 are most likely to practice EBF, reason being that they fall within the agile group.
b)Level of Education
High percentage of practice of EBF is found mostly among nursing mothers with very high level of education. Bryne et al76 opined that mothers knowledge of EBF determines practice. Improved maternal education enhances mothers’ understanding and appreciation of the demands and benefits of EBF, and empowers them to resist external interferences and pressures.
However, there has been studies were low level of practice was evident in highly educated mothers. Aneikan M et al62 in the University of Uyo teaching Hospital, Akwaibom state
demonstrated this in his study. This may be attributed to belief or economic status of the respondents.
c)Religion
Some religions require that the child be weaned at a very young age. Hindu is one of the religions practices in Timor- Leste. According to their practice, it is common that Timorese infants are introduced complementary foods at about the 4th month.
In Islam, It is believed that a good wife should not be seen nor heard, hence the covering from head to toe and the purdah system that restrict women from leaving the house to seek social or health services except with the permission of the mother in-law or husband. This is a moral norm that influences the pattern of behavior that has negative consequences on access of information including that of proper exclusive breast feeding practice and other services for improved wellbeing of mother and child.
Again, in Islam, breastfeeding in public places is viewed as a taboo due to the actual or gesture of exposing the breast. The breast is viewed exclusively as the property of the man. This defeats the aim of breast feeding on demand when such women are in public.
Furthermore, the predominant religion in the North Eastern and North Western states in Nigeria is Islam. These regions are currently under the siege of unmitigated Boko haram that believes western education is a taboo. This consequently has adversely affected access to quality information on exclusive breast feeding, as opined by Bryne et al76, mothers knowledge of EBF determines practice.
2.9.2 WORK PLACE ENVIRONMENT
This factor has been found crucial in the successful practice of EBF especially among working mothers. For example Singh100 found breastfeeding duration to be low among working women in Brazil due to reasons like short maternity leave, workplaces where babies were not allowed or lack of privacy for breast feeding. However, important changes in the extension of maternity leave of 120 days in various industries was associated with 97% of working women breastfeeding for a median duration of 150 days.
Higher socio economic status, nursery facilities and existence of a place in which to extract and store mother’s milk at work place have generally been associated with longer duration of breast feeding.101
2.10 ANTHROPOMETRY
Anthropometry is the measurement of the physical dimensions of the human body to approximate size, growth, and body composition as markers of nutritional status.102 The usual measurements taken include: weight; height; length (for children less than 2 years); head, mid- upper arm, and calf circumferences; and skin fold measures.
Anthropometry is used worldwide to represent nutritional status. In the recent Lancet series on Maternal and Child Under nutrition, it was the main method used for reporting on and calculating disability adjusted life years (DALYs) associated with nutrition. 103
Recent studies have demonstrated the applications of anthropometry to include the prediction of who will benefit from interventions, identifying social and economic inequity and evaluating responses to interventions.
Anthropometry can be used for various purposes, depending on the anthropometric indicators selected. For example weight-for-height (wasting) is useful for screening children at risk and for measuring short-term changes in nutritional status. However, weight-for-height is not appropriate for evaluating changes in a population over longer time periods. A clear understanding of the different use and interpretations of each anthropometric indicator will help to determine the most appropriate indicator(s) for program evaluation. 104
2.11 THE BUILDING BLOCKS FOR ANTHROPOMETRIC INDICES
1. Age
2. Sex
3. Length or Height
4. Weight
Each of these variables provides one piece of information about a person. When they are used together they can provide important information about a person’s nutritional status. The actual measurement of age, weight and height of children requires specific equipment and techniques.
When two of these variables are used together they are called an index. Three indices are commonly used in assessing the nutritional status of children:
•Weight-for-age;
•Weight-for-length or Weight-for-height.
•Length-for-age or Height-for-age;
There are many other anthropometric measures including mid-upper-arm circumference (MUAC); sitting height to standing height ratio (Cormic Index); and many skins fold measures.
2.12 COMPARISON OF ANTHROPOMETRIC DATA TO REFERENCE STANDARDS
2.12.1 NHCS/WHO REFERENCE STANDARDS
The reference standards most commonly used to standardize measurements were developed by the US National Center for Health Statistics (NCHS) and are recommended for international use by the World Health Organization. The reference population chosen by NCHS was a statistically valid random population of healthy infants and children. Questions have frequently been raised about the validity of the US-based NCHS reference standards for populations from other ethnic backgrounds. Available evidence suggests that until the age of approximately 10 years, children from well-nourished and healthy families throughout the world grow at approximately the same rate and attain the same height and weight as children from industrialized countries. The NCHS/WHO reference standards are available for children up to 18 years old but are most accurate when limited to use with children up to the age of 10 years.104
2.12.2 COMPARISONS TO THE REFERENCE STANDARDS
References are used to standardize a child’s measurement by comparing the child’s measurement with the median or average measure for children at the same age and sex. For example, if the length of a 3 month old boy is 57 cm, it would be difficult to know if that was reflective of a healthy 3 month old boy without comparison to a reference standard. The reference or median length for a population of 3 month old boys is 61.1 cm and the simple comparison of lengths would conclude that the child was almost 4 cm shorter than could be expected.
When describing the differences from the reference, a numeric value can be standardized to enable children of different ages and sexes to be compared. Using the example above, the boy is 4 cm shorter than the reference child but this does not take the age or the sex of the child into consideration. Comparing a 4 cm difference from the reference for a child 3 months old is not the same as a 4 cm difference from the reference for a 9 year old child, because of their relatively different body sizes. Taking age and sex into consideration, differences in measurements can be expressed a number of ways:
•Standard deviation units, or Z-scores
•Percentage of the median
•Percentiles.
To standardize reporting, USAID recommends that cooperating sponsors calculate percentages of children below cutoffs as well as other statistics using Z-scores. If Z-scores cannot be used, percentage of the median should be used.
2.13 HOW THEY ARE DEFINED
Stunting: Height for age / Length for age (HFA) < –2 SD of the WHO Child Growth
•Underweight: Weight for age (WFA) < –2 standard deviations (SD) of the WHO Child Growth Standards median105
•Wasting: Weight for height (WFH) < –2 SD of the WHO Child Growth Standards median105
•Overweight: Weight for height (WFH) > +2 SD of the WHO Child Growth Standards median105
The three indices are used to identify three nutritional conditions: underweight, stunting and wasting.
Underweight: Underweight, based on weight-for-age, is a composite measure of
stunting and wasting and is recommended as the indicator to assess changes in the magnitude of malnutrition over time.
Stunting: Low length-for-age, stemming from a slowing in the growth of the fetus and the child and resulting in a failure to achieve expected length as compared to a healthy, well nourished child of the same age, is a sign of stunting.104 Stunting is an indicator of past growth failure. It is associated with a number of long-term factors including chronic insufficient protein and energy intake, frequent infection, sustained inappropriate feeding practices and poverty. In children over 2 years of age, the effects of these long-term factors may not be reversible. For evaluation purposes, it is preferable to use children under 2 years of age because the prevalence of stunting in children of this age is likely to be more responsive to the impact of interventions than in older children. Data on prevalence of stunting in a community may be used in problem analysis in
designing interventions. Information on stunting for individual children is useful clinically as an aid to diagnosis. Stunting, based on height-for-age can be used for evaluation purposes but is not recommended for monitoring as it does not change in the short term such as 6 - 12 months.
Wasting: Wasting is the result of a weight falling significantly below the weight expected of a child of the same length or height. Wasting indicates current or acute malnutrition resulting from failure to gain weight or actual weight loss. Causes include inadequate food intake, incorrect feeding practices, disease, and infection or, more frequently, a combination of these factors. Wasting in individual children and population groups can change rapidly and shows marked seasonal patterns associated with changes in food availability or disease prevalence to which it is very sensitive. Because of its response to short-term influences, wasting may be used for screening or targeting purposes in emergency settings and is sometimes used for annual reporting. Weight-for-height is not advised for evaluation of change in a population since it is highly susceptible to seasonality.104
2.14 THE PRACTICE OF EXCLUSIVE BREASTFEEDING AND INFANT ANTHROPOMETRY
For the optimal nutrition of children under 2 years of age, it is considered important that they be exclusively breastfed for the first 6 months before being given complementary food. The burden of malnutrition in many developing countries continues to be high and slows the potential for individual, social and economic development.
High rates of wasting and stunting in children under 2 years of age reflect the serious challenges faced by many developing countries, including inadequate access to and availability of a healthy, varied diet, improper feeding and caring practices, and poor health and hygiene.106–108
Previous studies have been done to examine the extent to which an infant’s anthropometric status in the first year of life is associated with the duration of EBF during the first 6 months relative to breastfeeding supplemented with water or complementary foods during the same period.
Kuchenbecker et al109 in their study showed that Infants under 6 months of age who were exclusively breastfed were longer, heavier and less likely to be stunted than non-exclusively breastfed infants.
Studies in Vietnam among 6–18-month-old as well as 0–59-month-old children by Nakamori et al110 reported that early supplementation was negatively associated with both Weight for Age Z score (WAZ) and Length for Age Z score (LAZ). Subgroup analyses for younger and older infants were not done.
Muchina et al 111 revealed that the risk of being underweight was higher among children who had discontinued breastfeeding and those who had been exclusively breast fed for the first six months. According to a study done in western Kenya, children who were introduced to foods early had an increased risk of being underweight.121 In addition; discontinuation of breastfeeding before two years of age was found to be a significant (P_0.05) risk factor to underweight.
Malnutrition is one of the biggest health problems that the world currently faces and is associated with more than 41% of the deaths that occur annually in children from 6 to 24 months of age in developing countries which total approximately 2.3 million.112
World Health Organization in 2001 reported that 54% of all childhood mortality was attributable, directly or indirectly, to malnutrition.
Sub-Saharan Africa has a high prevalence of the different types of malnutrition, namely stunting, wasting and underweight.113 Feeding practices during infancy are critical for the growth, development and health of a child during the first two years of life114 and of importance for the early prevention of chronic degenerative diseases. Progress in improving infant and young child feeding practices in the developing world has been remarkably slow due to several factors like poverty and poor hygienic conditions.4 The 2003 NDHS shows that 38% of Nigeria children under the age of two years are stunted, 29% are underweight, and 9.2% are wasted.4 The Nigerian Food Consumption and Nutrition Survey of 2001-2003 observed similar trends among this age group with 42% stunted, 25 %underweight, and 9 % wasted.115
Several studies have been done in Nigeria to associate practice of EBF and child anthropometry. Ukegbu P et al116 in their study of growth patterns among EBF and non-EBF (NEBF) infants in Umuahia, revealed that none of the breastfeeding groups had any undue advantage at commencement of the study. It was observed that infants in both breastfeeding groups doubled their birth weight by the end of the 24 week, indicating that breast milk alone was satisfactory for growth of the EBF infants at this stage.
After the 14 week, the weight gain of the infants was reduced especially for the NEBF group. The lower weight gain of the NEBF infants during the first 14 weeks of life in the study could
have arisen from the fact that mothers introduced low energy and nutrient dense foods and liquids to displace the nutritionally superior breast milk. Studies117, 118 in Nigeria have decried the low quality of complementary foods used which in most cases are watery cereal gruels or other foods based on roots and tubers. Even where more nutritionally adequate commercial foods are available, they are so expensive that mothers use them sparingly and may over dilute them. This thus suggests that the exclusively breastfed infants distinctive growth pattern might be compromised when they are introduced to complementary foods at such early stage of life. Exclusive breastfeeding has been shown to have protective effects on the new born infant 119 and infants who are introduced early to complementary foods, do not fully benefit from it. It is therefore possible that apart from the low energy and nutrient densities of these foods and liquids, the NEBF infants could have at one time or the other suffered from some childhood diseases such as diarrhoea and respiratory tract infections which could have reduced their rate of weight gain. Though this was not assessed in their study.
Their study further showed that after the 14 week, there was a decline in weight gain of EBF infants even though they retained the higher mean weight achieved earlier. The decline in weight gain of the EBF infants should not necessarily be a cause for concern since this, according to Eregie120 could be a natural phenomenon especially if the infants are healthy and still thriving well. It is important for health workers to note this, so that mothers are not wrongly counselled that their breast milk production is inadequate and as such should introduce complementary foods at this stage. Some authors 121, 122 have noted that breastfed infants consume fewer calories and a lower volume of milk than formula-fed infants. In spite of this, the EBF infants grew better
than NEBF on the growth curve indicating probably better availability of energy and nutrients in breast milk.
The average monthly length increase obtained in their study was 2.56cm/month and 2.43cm/month in EBF and NEBF infants respectively. Average rate of increase reported for breastfed infants is 2.5cm/month.121, 123 It thus appeared that the infants in their study had similar length gain.
The values obtained were similar to that reported by other authors 122, 124, 125 on exclusively (EBF) and non-exclusively breastfed (NEBF) infants in Enugu, Rivers and Anambra states, respectively.
In conclusion their study showed that exclusive breastfeeding supported adequate growth of the study infants during the first six months of life.
A similar result was obtained in Ukegbu et al125 study in Nnewi. At 24 weeks of age EBF males and females achieved a better and more rapid growth in weight and length compared to those in the non-EBF group. Their study showed that none of the breastfeeding groups had an undue growth advantage at the commencement of the study. There was significant increase in mean weight and length among EBF infants when compared with the non-EBF infants at age 24 weeks.
This clearly indicates the adequacy of breast milk alone for infant growth during the first 24 weeks of life. EBF infants do not have their breast milk intake displaced by fluids with lower nutrient values.
The poorer weight gain in the non-EBF group might have been due to episodes of illness, as the absence of recurrent episodes of infection is necessary for normal growth and development.
Their study also showed that the age of maximum growth in weight and length at 0–6 weeks for the EBF infants and the subsequent decline at 10–14 weeks are similar to what is reported in other studies. The decline is suggested to be most likely a normal physiological phenomenon, since the infants were well and thriving.
In a study to assess nutritional status of under five children in akure south, Akorede et al1 result showed that the prevalence of stunted, wasted and underweight children were 12.5, 14.8, and 8.5% respectively. A few of the children (2.6%) had a MUAC less than 12.5cm while 3.4% had between 12.5-13.5cm (Acute malnutrition) and 94.1% had MUAC above 13.5cm. A clinical symptom of Protein Energy Malnutrition (PEM) was observed in 2.3% of the children. Several national and international organizations reported similar scenario.
From the empirical review of literature and available statistics on EBF practice and child nutritional status, urgent intervention is required to implement local educational programs for women of child-bearing age. Education must include topics such as breast feeding and its benefits. More so, infant and child nutrition programs should be given due impetus.