Knowledge and practice of exclusive breastfeeding among women with children aged between 9 and 12 months in Al Sabah Hospital, Juba, South Sudan

Abstract

Introduction: Breastfeeding is an important tool for preventing childhood illnesses, and obesity, and hypertension later on in life, and it reduces the cost of food for the family and the country. Appropriate practices that support exclusive breastfeeding in the first six months reduce childhood morbidity and mortality.

Aim: To assess mothers’ knowledge and practice of breastfeeding at El Sabbah Children’s hospital.

Methodology: 384 mothers with children aged 9 to 12 months attending the immunization and paediatric outpatient clinics were interviewed. Statistical Package for Social Sciences (SPSS) was used for data handling. Descriptive statistics and univariate logistic regression were used to analyse the data. 

Results: The majority of mothers were aged between 21 – 25 years (43.5%), had 2 - 4 children (55.5%) and primary education (48.2%). Most mothers had started breastfeeding within the first hour of delivery (76.8%), and knew that breastfeeding was nutritious to the baby. Parity and mother`s level of education were significant factors associated with exclusive breastfeeding (p<0.05). There was no statistically significant association between occupation, age of the mother, mode of delivery and exclusive breastfeeding (p>0.05). There was no statistical difference in rate of exclusive breastfeeding in mothers attending the OPD and the immunization clinic (p value=0.09).

Conclusion: Most mothers knew the benefits and definitions of exclusive breastfeeding. The early measures supporting breastfeeding are well practiced. Parity and mothers` education significantly affected exclusive breastfeeding.

Introduction

Breast milk is the optimal food for infants The World Health Organization (WHO) recommends that infants are breastfed exclusively (EBF) for their first six months, and then start complementary feeding while continuing to breastfeed for a minimum of two years [1].

The 2010 Sudan Household Health Survey [2] reported that only 45% of babies are exclusively breastfed for their first 6 months probably because of inadequate information on the importance of early initiation and giving only breast milk, inadequate family and community support, lack of counseling and mothers’ heavy workloads keeping them away from their children [3].

The primary objective of this study was to assess the practice of EBF during their babies first 6 months among mothers with infants now aged between 9 and 12 months attending the immunization and the outpatient clinics at El Sabbah Hospital, Juba. Secondary objectives were to:

• Assess mothers’ knowledge of EBF.
• Identify factors affecting the success of EBF.

Methodology

This was a cross-sectional descriptive hospital-based study conducted at El Sabbah Hospital from September 1^st to October 20^th 2014. The study population was women with children aged between 9 and 12 months attending the immunization and the paediatrics outpatient clinics. Consecutive sampling was done on mother/child pairs until the sample size of 384 was reached. 

A questionnaire was used to obtain information on socio-demographic status, birth related events, knowledge, and practices related to breastfeeding during the first six months, sources of breastfeeding education and family support.

A Statistical Package for Social Sciences (SPSS) was used for data entry and analysis. Descriptive analysis is presented in terms of mean, median. Frequencies are reported as numbers and percentages. Five point Likert scale was applied to questions on knowledge, ranging from strongly agreed (1) to strongly disagreed (5). The mean and SD was calculated for each answer. Univariate analysis was done.

Ethical approval was given by the Kenyatta National Hospital, University of Nairobi Ethics and Research Committee and the Directorate of Research and Planning, Ministry of Health, South Sudan. Consent was obtained from all mothers whose confidentiality was ensured.

Results

The median age of the 384 mothers was 23 years, IQR=20 - 26. 54.2 % of their children were females. Table 1 shows the demographic characteristics of the mothers.

 

Table 1. Characteristics of the mothers

Maternal data	n	Percent (%)
Mother’s age (n=340*)             16 - 19 years             20 - 29 years             30 – 39 years	37 263 40	10.8 77.3 11.8
Mode of delivery      Vaginal (SVD)      Caesarean section (CS)	370 14	96.4 3.7
Parity (n=353**)             1             2-4             Above 4	137 196 20	38.8 55.5 5.7
Level of Education                    None             Primary             Secondary             Tertiary	53 185 112 34	13.8 48.2 29.2 8.9
Occupation             Housewife             Salaried employee             Self-employed             Student	324 34 24 2	84.4 8.9 6.3 0.5
Marital status             Single             Married             Divorced             Widowed	112 261 10 1	29.2 67.9 2.6 0.3
Religion             Christian             Muslim	369 15	96.1 3.9
ANC visit        Yes        No	370 14	96.4 3.7
Number of ANC visits (n=348)             1             2             3           ˃ 4	11 30 55 252	3.1 8.6 15.8 72.4
Place of delivery             Hospital             Health Centre             Home	225 81 78	58.6 21.1 20.3

* excluding 40 missing data   ** excludes 31 missing data *** excludes 36 missing data

 

The rate of EBF was 63.2%. The majority (70%) of the mothers had skin-to-skin contact with their babies immediately after birth, 76.8% started breastfeeding in the first hour, and 98.1%. ‘roomed in’ with their babies. 40.6% of mothers gave prelacteal feeds. Only few (36) were not breastfeeding during the period of study, of which 75% stated that child refused by himself. Only 4.4% of the mothers stopped breastfeeding due to maternal breast problems.

The mothers’ knowledge about breastfeeding was assessed using the Likert scale (where 1 = strongly agree and 5 = strongly disagree) and given as means and SDs.

Most mothers agreed that:

• breastfeeding is nutritious to the baby (mean: 1.15, SD=0.53);
• increases  mother-baby bonding (mean 1.18, SD 0.46); 
• protects babies from infection (mean 1.25 SD 0.66);
• HIV can be transmitted via breast milk (mean: 1.57, SD: 0.66). .
• babies should be breastfed on demand day and night (mean: 1.04, SD: 0.22), from both breasts at each feed (mean: 1.06, SD: 0.27) and with good attachment to the breast (mean: 1.28, SD: 0.4).
• that a cup and spoon (mean: 1.74, SD: 0.77) and not a bottle should be used for feeding expressed milk (or formula) although use of expressed breast milk was low (mean 3.15, SD: 1.06).
• bottle feeding can cause diarrhoea (mean: 1.72, SD: 0.68).
• the definition of EBF was ‘giving only breast milk (and modern medicines only if prescribed)’ (mean: 1.39, SD: 0.54).

 Most mothers knew that and that the recommended duration for EBF was six months (84.9%).

The univariate and multivariate analysis of the factors affecting the success of breastfeeding among mothers are shown in Tables 2 and 3.

 

Table 2. Univariate analysis of factors affecting the success of exclusive breastfeeding

Variable	Category	Did you exclusively breastfeed
		Yes				No
		N			%	N	%	Chi square / *F	P value
Age	16-19 years	26			70.3%	11	29.7%	3.990	0.136
	20-29 years	219			83.3%	44	16.7%
	30-39 years	34			85.0%	6	15.0%
	>=40 years	0			0.0%	0	0.0%
Level of Education	None	46			93.9%	3	6.1%	14.358	0.002
	Primary	142			82.1%	31	17.9%
	Secondary	79			73.8%	28	26.2%
	University	30			96.8%	1	3.2%
	Others	0			0.0%	0	0.0%
Occupation	Housewife	250			81.7%	56	18.3%	0.917	0.632
	Salaried Employee	28			87.5%	4	12.5%
	Self Employed	19			86.4%	3	13.6%
	Student	0			0.0%	0	0.0%
	Others	0			0.0%	0	0.0%
Marital Status	Single	95			88.0%	13	12.0%	3.408	0.182
	Married	202			80.2%	50	19.8%
	Divorced	0			0.0%	0	0.0%
	Separated	0			0.0%	0	0.0%
	Widowed	1			100.0%	0	0.0%
Religion	Christian	285			82.1%	62	17.9%	1.074	0.300
	Muslim	13			92.9%	1	7.1%
	Others	0			0.0%	0	0.0%
ANC Visit	Yes	289			83.0%	59	17.0%	1.155	0.282
	No	7			70.0%	3	30.0%
Number of ANC visits	1		11	100.0%		0	0.0%	22.254	<0.0001
	2		30	100.0%		0	0.0%
	3		51	92.7%		4	7.3%
	>4		122	72.6%		46	27.4%
Mode of Delivery	SVD	281			82.2%	61	17.8%	1.736	0.784
	CS	12			92.3%	1	7.7%
Place of Delivery	Hospital	176			82.2%	38	17.8%	0.249	0.883
	Health Centre	56			81.2%	13	18.8%
	Home	64			84.2%	12	15.8%
	Others	0			0.0%	0	0.0%
Parity	1	127			96.2%	5	3.8%	76.250	<0.0001
	2	65			69.1%	29	30.9%
	3	47			97.9%	1	2.1%
	4	16			42.1%	22	57.9%
	>5	13			72.2%	5	27.8%
Mean mothers’ age		22.77				24.10		2.509	0.114
Parity		2.03				2.95		23.828	<0.0001

 

Table 3. Logistic regression

	Coefficient	Standard error of coefficient	P value	OR	95% C.I. for OR
					Lower	Upper
Mother’s age	-.057	.032	.072	.944	.887	1.005
Parity	.559	.121	.000	1.749	1.380	2.217
Education level	.483	.205	.018	1.621	1.085	2.423

Adjusting for mother’s age, women with fewer children and those with lower level of education were more likely to exclusively breastfeed.

Discussion

The study showed that more mothers tend to breastfeed their infants for the first six months than previously reported [2]. The factor that support the success of EBF in Tanzania and Kenya is starting within the first one or two hours after delivery [(4 5].  We found that of those who did not start breastfeeding in the first hour had assumed that there was no milk and 7% reported that colostrum was harmful to the baby

More than 70% of the mothers had skin-to-skin contact with their babies immediately after birth, much higher than the 39.7% in the study in California [6]. Other good practices were not offering prelacteal feeds and rooming-in with babies, which were similar or better than in other studies [4,7,8]. Most of the children got sick at some point during their first 6 months but only 20 mothers stopped breastfeeding during the period of sickness. The fear that mothers’ breast milk can cause diarrhoea or aggravate a child’s illness contributed to this.

Our mothers had not expressed breast milk. This practice is not accepted by most of the mothers, partly because they did not know about it or thought the milk would be bad if kept for long.  Most mothers started complementary feeding after six months of age (67.7%).

Forty one mothers had stopped breastfeeding at the time of the study. Child’s refusal to breastfeed or mother becoming pregnant were the frequent reasons given – also a common finding in Tanzania [9 4].

Mothers tended to breastfeed longer where there was support from husbands or provision of work-based designated areas for breastfeeding.

Most mothers knew the advantages of breastfeeding, that HIV could be transmitted in milk, the definition of EBF and proper techniques of breastfeeding - all indications of good ANC practices and family support.

Some studies have shown that women who had a vaginal delivery were more likely to breastfeed exclusively [9]. However, no association was found in this study, as similarly reported in Kenya [10]. Widespread use of spinal anaesthesia for Caesarean Section (CS) deliveries could play a role in allowing mothers to initiate breastfeeding within one hour of birth; also the myth that CS delivery affects mothers’ belly shape makes them work hard on EBF so as ensure quick uterine involution and later on a small belly.

This study found that parity, mother’s level of education, age and status were associated with EBF.  A longer duration of EBF was associated with first time parenthood [10] and level of education. The lower the level of education the more likely the mother was to exclusively breastfeed; however, the majority of university-educated mothers exclusively breastfed. Other studies contradict this assertion [11].

There were no significant association with marital status or rate of EBF.  Infants exclusively breastfed should be protected against infection, so we should expect less sickness compared to non-exclusively breastfed babies. But in this study no difference was found.

Conclusion 

Knowledge on breastfeeding was generally good, although use of expressed breast milk was low. Early practices that support exclusive breastfeeding were done by the majority of the mothers. Parity and maternal level of education affect the success of exclusive breastfeeding.

Recommendations

1. Carry out more training and awareness campaigns to maintain the high rate of EBF.
2. Conduct house-to-house surveys to establish more in-depth understanding on the practices and knowledge of EBF. 
3. Advocate the use of expressed breast milk.

Study limitations

1. Recall bias: some mothers could not recall all the details of their practices in the first six months.
2. The clinical sample of women represented a group which might be more compliant and better informed about infant feeding than a random population sample of women.
3. Being more informed, mothers who come to the hospital might give the desired answers even if they do not practice.
4. The population studied might not represent the whole country, as representatives of some of the states were too small

References

1. World Health Organization 2016. Infant and young child feeding. Fact sheet. Updated September 2016  http://www.who.int/mediacentre/factsheets/fs342/en/
2. Sudan Household Health Survey 2010 http://reliefweb.int/sites/reliefweb.int/files/resources/MICS4_Sudan_2010.pdf
3. UNICEF Press release. Breastfeeding. South Sudan. 2013. https://www.unicef.org/esaro/5440_13132.html]
4. Shirima R, Gebre M, Greiner T. Information and socioeconomic factors associated with early breastfeeding practices in rural and urban Morogoro, Tanzania 2001 Acta Paediatr. 2001 90(8):936-42. https://www.ncbi.nlm.nih.gov/pubmed/11529546
5. Ganu D. Assessing exclusive breastfeeding knowledge and practices among mothers of Kajiado District of Kenya, Kenya 2013 Am Public Health Assoc 141^st annual meeting https://apha.confex.com/apha/141am/webprogram/Paper284120.html
6. Bramson L et al. Effect of early skin to skin mother contact during the first three hours following birth on exclusive breastfeeding during maternity hospital stay, J Hum Lact: 2010 26 (2) 130-137
7. Radwan H. Pattern and determinants of breastfeeding and complementary feeding practices of Emirati mothers in the United Arab Emirates, BMC Public Health 2013,13 :171
8. Salih MA, El Bushra HM, Satti SA, Ahmed MA, Kamil IA. Attitude and practices of breastfeeding in Sudanese urban and rural communities, Sudan, 1993. US National Library of Medicine National Institutes of Health.
9. Kuyper E, Vitta B, Dewey K. Implication of Caesarean section delivery on breastfeeding outcomes and strategy to support breastfeeding., Alive and Thrive Technical Brief, issue 8, Feb 2014  http://www.health-e-learning.com/resources/articles/275-implications-for-cesarean-delivery
10. Naanya V, Young mothers, first time parenthood and exclusive breastfeeding in Kenya, African Journal of Reproductive Health, 12,(3) Dec. 2008
11. Grummer-Strawn LM, Shewly K. Progress in protecting, promoting and supporting breastfeeding. 1984-2009, Breastfeeding Med 2009; 4: S31-9

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