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Correspondence to Author:  Chinedu Onyezobi, 

Project implementation Unit, Kaduna State Ministry of Health.

Abstract:

This study presents findings from a cross-sectional survey conducted among mothers and caregivers of children under 5 in Kaduna State, Nigeria. Out of the 1647 collected questionnaires, 77.5% were validated for analysis. Results reveal that 53.3% of the women were aged 20-29 years, with older adolescent mothers (18-19 years) comprising 7.8%. The majority were married (97.8%), and over two-thirds had at least primary education (69.5%). While 54.5% identified as housewives, 28.7% engaged in petty trading, and 12.3% pursued farming full-time.

Table 2 in the appendix indicates good knowledge of exclusive breastfeeding (EBF) practices, with 88.4% knowing breastfeeding should start immediately after birth. However, EBF prevalence was only 33.3%, higher among women with more than secondary education (43.2%) and those aged 20-29 years (35.4%). Positive perceptions toward EBF were evident, but misconceptions persisted, impacting practice. Social norms influenced some contradictory behaviors, such as early introduction of water (51%). Self-efficacy emerged as a strong driver, with 86% confident in making feeding decisions. Barriers to EBF included age and social norms, while perception and self-efficacy were identified as drivers. The logistic regression model explained 50.3% of EBF variance, emphasizing the need for targeted interventions. Despite good knowledge, the suboptimal EBF prevalence underscores the importance of addressing multifaceted barriers to enhance breastfeeding practices.

Introduction

In 2018, a global total of 2.7 million children died due to malnutrition, comprising 45% of worldwide fatalities, as reported by UNICEF. The majority of these deaths occurred in Africa and Asia. Despite advocacy for exclusive breastfeeding in sub-Saharan Africa, a significant number of children in the region do not receive the nutritional benefits for the recommended six months. Malnourished children increased from 3.7 million in 2017 to 6.3 million in 2018, according to UNICEF. Studies suggest that a substantial percentage of annual neonatal deaths could have been prevented with breastfeeding (Ekambaram et al., 2010; Victora et al., 2016). Insufficient nutrition in early childhood can adversely affect physical and emotional development, impacting achievements and productivity in adulthood. Providing necessary nutrients through breastfeeding is widely acknowledged, offering economic and environmental benefits (Rollins et al., 2016; Hansen, 2016). Exclusive breastfeeding involves providing infants with only breast milk, but allows for oral rehydration solution (ORS), vitamins, minerals, and medications. After six months, complementary foods are recommended alongside breastfeeding for up to two years. Optimal breastfeeding is estimated to prevent 20,000 maternal deaths from breast cancer annually (Rollins et al., 2016; UNICEF, 2018). The World Health Organization recommends exclusive breastfeeding for six months, aiming for two years, but global rates vary. In 2018, only 47% of mothers worldwide exclusively breastfed until six months. Rates differ across continents: Europe 43.7%, America 43.9%, Asia 55.2%, Africa 41.7% (Zong et al., 2021). Sub-Saharan Africa, including Nigeria, faces low exclusive breastfeeding rates (SUN, 2018; MICS 2017; NDHS, 2008). In Nigeria, only 13% practiced exclusive breastfeeding in 2017, below the WHO-recommended 90% (Jones et al., 2003). Improving exclusive breastfeeding requires proper health education, support, and motivation (Mogre et al., 2016). Understanding the knowledge, attitudes, and practices surrounding breastfeeding is crucial for reducing child mortality and promoting growth and immunity (WHO/UNICEF, 2017). Breastfeeding attitudes, considered modifiable elements, play a role in shaping exclusive breastfeeding behaviors (Casal et al., 2017; Chekol et al., 2022). The Society for Family Health, in collaboration with the Kaduna State Ministry of Health, conducted a baseline assessment to uncover barriers to exclusive breastfeeding practices among mothers and caregivers of children under 5 years in Kaduna state. Additionally, the study aims to investigate the determinants of breastfeeding practices among women.

Methodology

Study Design, Settings, and Sample Selection A comprehensive cross-sectional household survey was conducted among mothers of children under the age of 5 years in Kaduna State. The study focused on women within the reproductive age range of 15-49 years residing in the state, specifically in eleven (11) out of the twenty-three (23) local government areas: Giwa, Soba, Zaria, Sabongari, Kudan Makarfi, Kubau, Lere, Kauru, Birningwari, and Igabi. The sampling process involved a multi-stage cluster sampling technique, with clusters drawn independently for each area using the probability proportional to size (PPS) method. Given the recent population movements, an updated sampling frame for the state was created, utilizing a list of the smallest possible units (villages or camps) for sampling purposes. Population estimates from the January 2019 polio campaign micro plan and VTS population estimates were employed for selection.

In the first stage, primary sampling units (clusters) were randomly selected using the probability proportional to size method. To mitigate potential challenges in accessing selected clusters during data collection, reserve clusters were also chosen at this stage using fractional interval systematic sampling. The second stage involved the systematic random selection of households within each cluster, using the same fractional interval systematic random sampling method. A total of 1647 mothers were randomly chosen and administered a well-validated proprietary electronic questionnaire. The questionnaire was conducted face-toface with the women in a comfortable setting within their households. Prior to the survey, the questionnaire underwent pre-testing to ensure its validity and reliability. The reliability test indicated a Cronbach alpha of 0.806 for knowledge, 0.875 for self-efficacy, and 0.926 for perception. Participants were approached for consent, emphasizing the voluntary nature of their participation.

Sample Size Determination

The sample size for this nutrition survey was calculated using the USAID Feed the Future Population-based Sampling Guide (Stukel, 2018). With this formula, we will be conducting 1,135 interviews with caregivers of children 0-59 months as shown in the table below:

Data Analysis

The data analysis was done using SPSS Version 25.0. Both descriptive and inferential statistics were employed to analyze the data. Descriptive statistics were used to describe the demographic information of the respondents while inferential statistics were used to test the hypothesis. Binary logistic regression was employed as an inferential statistic to assess the effect of age, social norms, perception, and self-efficacies on the practice of exclusive breastfeeding. The statistical significance was set at a 95% confidence level. Logistic regression was performed to ascertain the effect of perception, social norms, self-efficacies and socio-demographics of the women on the likelihood that they practice exclusive breastfeeding.

Results

Demographic characteristics of the respondents From Table 1 below, out of the 1647 questionnaires collected, a total of 1,277 underwent screening and validation for analysis, resulting in a response rate of 77.5%. Among the 1,277 women included in the analysis, a majority (53.3%) fell within the age range of 20-29 years. Older adolescent mothers (18-19 years) constituted 7.8% of the overall sample. Most of these women were married (97.8%), with a small percentage being widowed (1.4%). In terms of education, over two-thirds had attained at least primary education (69.5%), while one-third had no formal educational background. More than half identified as housewives (54.5%), while a notable portion engaged in petty trading (28.7%). Those who pursued farming as a full-time occupation accounted for 12.3% of the total sample population.

Knowledge on Infant and Young Child Feeding and Practice of Exclusive breastfeeding

From Table 2 below, most of the women interviewed have a good knowledge of exclusive breastfeeding practice as the majority know that breastfeeding of babies should start immediately after birth (88.4%). More than eight per cent (87.9%) of these women understand that women must give the first milk (colostrum) to their babies immediately or at most 30 minutes after birth as this contains a high level of proteinous antibodies that fights infections and bacteria. Nearly half (46.6%) of the women correctly believed that until infants turn 6 months, they should not receive water even under extreme weather conditions. However, while over 71% of the women understood that infrequent breastfeeding and not emptying the breasts during the feeding lead to fullness/soreness of the breasts, only a little over a fourth of the women recognized that inconsistent breastfeeding often causes pains in the nipple areas.

Social Norms towards Practice of Exclusive Breastfeeding

Not so many women were influenced by the social norm; 80% of them still believed that a baby should be put to breastmilk under 30 minutes after birth, and about 72% concorded to exclusively feeding infants until 6 months after delivery. Nearly 63% and 64% agreed on feeding infants with a high protein diet and fruits and vegetables, respectively, after 6 months. However, the Social Norm exerted some influence that opposed EBF as demonstrated by some women. More than half (51%) of the women approved of giving water to infants before they turn 6 months, and over 44% each fed their children with infant formulas and semi-solid food before they turn 6 months.

The overall model is statistically significant (χ2(11) = 572.894, p < .0005), indicating that at least one of the independent variables (age, social norms, behavioural beliefs, and self-efficacy) is a significant predictor of the practice of exclusive breastfeeding. The coefficient of age (B) is -0.027, indicating that for each one-unit increase in the age of the respondent, the log-odds of practicing exclusive breastfeeding decrease by 0.027 units. The Wald statistic is 4.822, with 1 degree of freedom, and the p-value is 0.028, suggesting that age of the respondent is a statistically significant predictor. The odds ratio (Exp(B)) is 0.974, indicating that holding other variables constant, for each one-unit increase in the age of the respondent, the odds of practicing exclusive breastfeeding decrease by 2.6%. The coefficient of behavioural beliefs is 0.098, suggesting that for each one-unit increase in beliefs, the log-odds of practicing exclusive breastfeeding increase by 0.098 units. The Wald statistic is 25.356, with 1 degree of freedom, and the p-value is < 0.0005, indicating that beliefs are a statistically significant predictor. The odds ratio is 1.103, meaning that holding other variables constant, for each one-unit increase in beliefs, the odds of practicing exclusive breastfeeding increase by 10.3%. The coefficient of self-efficacy is 0.114, indicating that for each one-unit increase in self-efficacy, the log-odds of practicing exclusive breastfeeding increase by 0.114 units. The Wald statistic is 79.024, with 1 degree of freedom, and the p-value is < 0.0005, showing that self-efficacy is a statistically significant predictor. The odds ratio is 1.121, indicating that holding other variables constant, for each one-unit increase in self-efficacy, the odds of practicing exclusive breastfeeding increase by 12.1%. The coefficient of social norm is -0.305, suggesting that for each one-unit increase in the social norm, the log-odds of practicing exclusive breastfeeding decrease by 0.305 units. The Wald statistic is 260.916, with 1 degree of freedom, and the p-value is < 0.0005, indicating that social norm is a statistically significant predictor. The odds ratio is 0.737, meaning that holding other variables constant, for each oneunit increase in social norm, the odds of practicing exclusive breastfeeding decrease by 26.3% >

Discussion

The socio-demographic characteristics of the study participants provide a context for understanding the breastfeeding practices. The majority of women were within the age range of 20-29 years, married, and had attained at least primary education. The occupation distribution showed a significant number of housewives, followed by those engaged in petty trading and farming. This demographic profile may influence the access to information and resources, thus impacting breastfeeding practices. The prevalence rates observed among specific groups highlight the importance of tailoring interventions to address the unique challenges and influences faced by different segments of the population. Despite the seemingly good knowledge about EBF among women, there is a notable gap between knowledge and practice. However, this suggests that there is room for improvement in enhancing women’s understanding of optimal breastfeeding practices. The FAO guidelines emphasize that a nutrition-related knowledge score below 70% is insufficient and necessitate urgent nutrition-education intervention (Fautsch M & Glasauer, 2014).

The findings on cognitive factors and beliefs provide context for understanding the challenges in translating knowledge into practice. The discrepancy between knowledge and practice emphasizes the need for comprehensive nutrition education interventions that go beyond basic awareness and address the specific cognitive beliefs influencing breastfeeding decisions. Moreover, the acknowledgment that knowledge alone may not translate into practice is crucial. This is in line with the identified factors such as cognitive beliefs, social norms, and self-efficacy, which collectively contribute to shaping breastfeeding behaviors. While knowledge is a crucial foundation, it needs to be complemented by targeted interventions that address the complex interplay of cognitive, emotional, and social factors influencing breastfeeding practices. This is Consistent with the Ideation Model of Strategic Communication and Behavior Change, with various cognitive, emotional, and social domains playing a crucial role in women’s breastfeeding decisions. This highlights the multifaceted nature of factors influencing exclusive breastfeeding practices among women in northwestern Nigeria. Addressing cognitive beliefs, enhancing self-efficacy, and understanding the impact of social norms are crucial components of effective interventions aimed at promoting optimal breastfeeding practices in the region.

Conclusions

In conclusion, this cross-sectional study sheds light on the complex dynamics influencing exclusive breastfeeding (EBF) practices among mothers and caregivers of children under 5 in Kaduna State, Nigeria. The findings highlight a substantial gap between knowledge and actual EBF practices, with a prevalence of only 33.3%, falling below the recommended standards. Despite good knowledge levels, various factors contribute to the suboptimal EBF rates.

The study underscores the need for targeted interventions that go beyond mere knowledge dissemination. While knowledge is crucial, addressing barriers such as social norms, misconceptions, and age-related influences is essential. The identified drivers of EBF—perception and self-efficacy— present key areas for intervention strategies. Enhancing women’s confidence and correcting misconceptions through comprehensive educational programs may significantly impact EBF rates.

Moreover, the study emphasizes the importance of recognizing and challenging prevailing social norms that contribute to contradictory behaviors, such as the early introduction of water. Efforts should be directed towards community engagement and awareness campaigns to foster a supportive environment for EBF practices.

The regression analysis provides valuable insights into the specific factors influencing EBF, offering a foundation for tailored interventions. However, the identified barriers and drivers represent just a fraction of the complex interplay affecting breastfeeding practices. Future research and interventions should consider the broader socio-cultural context to develop holistic strategies that address the multifaceted challenges faced by mothers and caregivers. Ultimately, improving EBF rates requires a collaborative effort from healthcare professionals, policymakers, and community stakeholders. By fostering an environment that supports and encourages exclusive breastfeeding, we can work towards ensuring optimal infant nutrition, overall health, and the wellbeing of both mothers and children in Kaduna State.

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Citation:

Chinedu Onyezobi. Demystifying Barriers to and Drivers of Exclusive Breastfeeding Practice – A Cross-Sectional Study Among Mothers & Caregivers of Children Under 5 in Kaduna State, Nigeria.. Journal of Nutrition and Food Science Research 2024.