knowledge, attitude and practice of breast feeding - a case study bhavana singh

European Journal of Scientific Research ISSN 1450-216X Vol.40 No.3 (2010), pp.404-422 © EuroJournals Publishing, Inc. 2010 http://www.eurojournals.com/ejsr.htm

Knowledge, Attitude and Practice of Breast

Feeding - A Case Study

Bhavana Singh University Hospital, Kwame Nkrumah

University of Science and Technology, Kumasi, Ghana

Abstract

Breastfeeding incidence is declining in almost all parts of the world despite all its nutritional and immunological benefits. This paper presents findings of a study in which 200 mothers in Kumasi, Ashanti Region were interviewed to assess their knowledge, attitude and practices of Breast feeding at the CWC/MCHC which is based in the centre of the town. An attempt has also been made to assess the ‘rooming-in’ practices in our hospitals. The study shows that the prevalence of breastfeeding among the women was 100% and average duration of breastfeeding was about 18 months or longer. However, weaning was found to be done at very early ages of 2-4 months and 38.0% of mothers admitted to giving water to their babies soon after birth implying most mothers do not know what weaning actually meant. The most common weaning food used were Koko and weanimix. Besides,most common reason for early weaning were fear of adequate milk supply (56.0%) followed by breast and nipple soreness. Most mothers were found to know the importance of breast milk as being nutritious (100%), healthier for children (97%), protecting their children from disease (80.0%), promoting bonding between mother and child (99%) and being cheaper than buying supplements (81.0). However, 38.0% of mothers disagreed to the contraceptives benefits of breastfeeding.

1.0. Introduction Breast feeding in known to be the best way to feed infant by providing the psychological and health benefit to both the mother and child. It is therefore considered physiologically, biochemically, Immunologically and psychologically suited for this.

However, there has been a general decline in the practice of breast feeding both in terms of prevalence and duration in the past few decades.

Death rates in the third world countries are lower among breast fed babies and breast fed babies are having fewer infection than formula fed babies, says Ruth Lawerence. M.D, a spokesman for the American Academy of paediatrics. “And everyday between 3000 and 4000 infants die from diarrhoea and acute respiratory infection because of inadequate breast milk given to them (1)”.

UNICEF and WHO recommends that should exclusively breast feed for first 4 to 6 months of life and continue breast feeding together with weaning food up to and beyond second year of life. 1.1 Duration of Breast Feeding

It has been observed that breast feeding duration varies from one country or geographic region to another. Study in Eldoret District Hospital, Kenya by Esmai etal found only 32% who breast fed their children up to 2 years, 33% up to 12 months and 13% stopping at 6 month (6).

Knowledge, Attitude and Practice of Breast Feeding - A Case Study 405

In Bangkok and Bogota, the median duration for lactation was less than 7 months. Nairobi exhibited a longer duration of 16 months and in Semarang, median duration was 20 months (7). In Latin America and the Caribbean, only 35% to 60% of their children continue being break fed up to an age of 6 month (8) and within Latin America, in Mexico, frequency of breast feeding has declined notably. A study by Maria etal showed only 34.8% of the study infant breast fed for not more than 1 month (9). 1.2 Duration of Exclusive Breast Feeding

Although, breast feeding practices has declined world-wide, exclusive breast feeding does not even seem to be the norm in any part of the world either. The increase use of infant formula and substitutes too early in a baby’s life contributes to the high degree of under development and malnutrition in our children. And babies given cow’s milk and formula early in their lives has over 60% more risk of being malnourished (5). As stated earlier, exclusive breast feeding for 4 to 6 month is very important and it is sufficient for every child. Most commonest cause of decline in exclusive breast feeding is mother perception about insufficient breast milk.

In Brazil, mean duration of exclusive breast feeding is only 28.9 days. It has been found in a study that only 14% of mothers exclusively breast fed for 120 days of Age and only 4% for 180 days (10). In Malaysia, however, the results are no better as only 25% of babies are breast fed exclusively at 2 months(10). In westernised cities of Bogota and Bankok, only 12% and 21% of babies respectively are breast fed exclusively at 1 month. In Nairobi, the decline is no better. Only 20% of babies are breast fed exclusively up to 2 months. In Jemarang however, about 42.0% of babies were exclusively breast fed for 2 months (7). 1.3. Reasons for Early Weaning

Duration of breast feeding practices and exclusive breast feeding practices are declining and various factor have been associated world-wide which includes social factors, practice in health care facilities, advertising and promotion of infant feeding products.

In Nicaragua, among women living in poor neighbourhood, exclusive breast feeding was considered harmful for mother among the community and breast milk alone was thought not be sufficient nourishment for the child (11). In rural community of Mexico, Artificial lactation and easily weaning are typical of small families, with high educational level of mothers, better living condition and contact with medical personells (12).

Oromo women who take up residence in U.S.A. tend to wean their babies too early due to strong taboos against bare breast, social situations which require them to be seperated from their babies, and admit to formula fed infants gaining weight more readily and also getting formula free as another cause for early introduction of supplement (13).

However, in Kuala Lumpur, mothers who followed exclusive breast feeding were more likely those who had had an antenatal plan to breast feed, not in paid employment postnatally and also of older age group, more than 27 years old, had female infants and of Indian ethnicity (14). In this study, male genders as an adverse factor to poor exclusive breast feeding rate is an interesting limiting factor which requires further evaluation.

Three risk factors were associated with early weaning in Mexico as found by Maria and Gultermo and there were maternal age less than 20 years. single mothers and social status of the main family provider other than worker i.e. employee, professional (9).

Early weaning age seems to be prominent in all part of the world. The question of whether bottle feeding is making women breast feed less should also be considered. In Bogota, over two third of the women who no longer breast fed but rather bottle fed stated that bottles were added because of perceived problems with milk production and also for the satisfaction of the child. In Bangkok, 40% of

406 Bhavana Singh

all decision were also for the same reason. In Nairobi, mothers perceive the use of bottle as beneficial for the baby and add it as a tonic or nutrients booster to breast milk (7).

In Bangkok, 5% of women, however, disliked breast feeding or had other purely personal reasons. In the two cultures of Nairobi and Jemarang, where breast feeding is common for long duration, weaning fairly often occurred among some on other because of a new pregnancy (7).

In Kuala Lumpur, Malaysia, study by Cheye et.al. found that 26% of the mothers were exclusively breast fed using and they were mothers who had breast feeding difficulties or had only up to or less than 9 years of schooling and were of Chinese descent. However, among mothers who weaned at an early age, the reasons that were given insufficient milk supply, followed by breast and nipple problems and then maternal tiredness and illness (14). 1.4. Work and Breast Feeding

Breast feeding duration was also found to be low among working women due to reasons like short maternity leave, workplaces where babies were not allowed and even in places where they were allowed, there was no privacy for breast feeding the babies or for expressing milk to bring to them.

In Brazil, however, important changes in the extension of the maternity leave of 120 days in various industries was associated with 97% of working women breast feeding 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 were associated with factors of longer duration of breast feeding (15). 1.5. Attitudes towards Colostrum

Condition as above if provided will maintain long duration of breast feeding even among working women. In many ways, even though, breast feeding is a universal practice, there are cultural aspects that vary considerably about Colostrum which is the most nutritious part of breast milk and is secreted for the first 2 days and on the 3rd and 4th days the secretion changes to normal breast milk. Colostrum is a yellowish fluid containing large fat globules, which has a high mineral and moderate protein and relatively low sugar content of antibodies, especially secreatory IgA, which plays n important part in protection against infection. Colostrum may help to clear the small intestine if it becomes contaminated with infected material swallowed during the birth process.

In initial breast production of “yellow water” (i.e. Colostrum) is viewed as nutritionally useless “just like water” and it is sometimes expressed and discarded. Oromo people believe so and see water as void of nutrition and do not drink it. Even breast feeding among them is initiated in second or third day of life when the mothers milk comes in, prior to this infants are given fresh butter which “cleanses the gut”.

The practice is similar among the rural communities of a semi–arid district of Rajasthan, India, where 77% of study population discarded Colostrum. However, the practice of prolonged breast feeding and delayed supplementation to infants are rampant in this area. The mean age at weaning is 27.1 months, again not only affect the health status of mother and their children but also leads to under nutrition among both (16). 1.6. Rooming-in Practices and Factors Affecting the Practice

Twenty-four hour Rooming in (or access to baby 24 hours a day) encourages frequent feeding. This practice will prevent or reduce engorgement and jaundice and will establish mature milk faster. Allowing baby to suckle easily post – deliver is helpful in establishing close contact between mother and baby as well.

A study in Indonesia showed that most babies, 61% began sucking within the first 12 hours after birth but only a small proportion, 7% were put to breast with 1st hours of deliver with 18% who delayed beyond 24 hours especially among mothers who experienced non-normal delivery such as breech birth, vaccum extraction and even caesarian section. The reason for delayed initiation of breast


feeding given were rather centred on breast feeding problem like breast / nipple problem like soreness and engorgement and a perception of insufficient breast milk. In some cases, they were not breast feeding because their infants were premature and therefore thought they were weak (17).

Among the Oromos most women, initiated breast feeding second or third day because they regarded the Colostrum as nutritionally useless (13). A clinic based cross –sectional study conducted in Nagpur India revealed among 62.67% of children, breast feeding was initiated within 24 hours after birth. Rooming in practices has been known to promote breast feeding. Bed sharing has even been thought to prolong breast feeding duration and thought to be protective against sudden infant death syndrome (SIDS). A study in Indiana, U.S.A. revealed that routinely bed sharing infants breast fed approximately three times longer during night than infants who routinely slept separately (18). 1.7. Effect of Early Weaning

The above literature about prevalence, and associated reasons have to be taken into consideration and educate mothers about the disadvantages of early supplementation and the advantages of breast feeding fully. There are various disadvantages of early weaning. Weaning early in age is harmful in many ways as food and water if not well processed are well recognised vehicles of Diarrhoea infection caused by bacteria, virus and protozoa.

Studies have found poor nutritional status to be significantly association with earlier complimentary feeding. (19). Early weaning is also known to be cause of anaemia in the first year life (19). Childhood anaemia is another very important cause of death in children in developing countries.

Another association has showed the declining incidence of coeliac disease and transient gluten intolerance associated with increased of initial breast feeding. (20). This is very important finding as coeliac disease is cause of chronic diarrhoea.

In African countries where weaning foods were cereals, study in Ethiopia showed that these and other foods given to weaning age children were found to be grossly contaminated most frequently with Enterobecter sp. (21). This calls educating the community the relationship between contamination of weaning such as reheating of weaning foods before serving infants and children.

Lower weight of children on weaning diet can be attributed to lack of sufficient knowledge and exposure in preparing well balanced diet from locally available food stuffs by mothers (22). Learning to prepare weaning food at home means less dependency on commercial weaning food which may not be readily available and even if available are expensive and not within the reach of many mothers(22).

Early introduction of bottle feeding and prolonged bottle feeding is also associated with increased incidence of dental caries in children (23). There are profound change of immune activity during infancy from suppression during breast feeding, activation with weaning and later intrinsic down regulation after weaning. Breast feeding, as well as, protecting against infections, seems to have a fundamental rule in modifying the immune system against certain disease status(24). 1.8. Importance of Breast Feeding

A study has demonstrated breast feeding reduces risk of respiratory illness in infant both in terms of duration and severity (25). Not only does it reduce respiratory tract infection but it is also associated with lower rates of varieties of infant illness at the community level (26). Studies have also shown that bone mineral content is not reduced despite low vitamin D status in breast milk fed infant versus cow’s milk based formula fed infant (27).

Several studies have also shown a modest beneficial effect of breast feeding on cognitive development after controlling for socio demographic confounders (28). Frequent breast feeding and in low birth weight infants resulted in fewer neonatal complication (29). Health provides have only recently been paying attention to the attitudes of women toward Antenatal care programmes (30). Success of an ANC programme depends to a greater or lesser degree on the co-operation of women. One of the aims of increased satisfaction with ANC is to achieve better compliance with the advice given, which leads to improve pregnancy out come and health as well. In developing countries, the

408 Bhavana Singh

utlization of ANC is known to be low and this is usually attributed to a variety of socio-economic factors (31) major problems limiting access to ANC as found by a study is also lack of money to pay for booking fees, staff ignorance regarding the best time to book to suit the mothers, lack of privacy and insufficient staff at the clinic (32). Infrastructural changes at policy making levels can solve some of the problems of ANC programmes because prenatal breast feeding education is associated with longer duration and incidence of breast feeding (33).

The training of health workers in breast feeding and lactation management enhances professional recommendations on breast feeding (34). The training of heath workers however can play an important role in the promotion, protection and support feeding. The health worker has a very positive impact on at least one aspect of breast feeding behaviour in the community and that is mother timely intention of breast feeding.

However, findings from studies have shown the presence of HIV-1 has been detected in both cell-free and cellular fractures of human milk and Colostrum. There are higher overall vertical transmission rates in developing countries (ranges, 25-30%) than in Europe (15-20%) and the U.S.A. (16-30%). Studies have also shown that in setting where the main causes of the infant mortality are infectious diseases, HIV-1 prevalence and the risk of mortality from artificial feeding also tend to be high. Change to artificial feeding by all or infected mother alone would result in declined child survival.

In contrast, in setting where the adverse effect of artificial feeding on mortality are small, artificial feeding by known HIV-infected mothers would increase child survival (35). Breast feeding has also been recognised as playing an important significant role in birth spacing by virtue of inducing high levels of prolactin which inhibits ovulation. This state of infertility is achieved by a sufficient degree of nipple stimulation from breast feeding more frequent or intense suckling maintain contraception. Lactational cmenonhoea method is 98% effective in preventing pregnancy for up to 6 months.

A healthy start in life is the most precious gift one can give to a new born child. Breast milk can make the difference between healthy growth and malnutrition, between life and

death. When it comes to nutrition, the best first food for babies is breast milk. Breast milk is necessary for babies of 6 to 12 months. Solid food should be introduced when the

baby is 4 to 6 months old but a baby should drink breast milk for a full year or more as human milk contains just the right amount of nutrients for the development and growth of the child. It has been found that everyday, between 3000 & 4000 infants die from diarrhoea and acute respiratory tract infection because the ability to feed them adequately has been taken away from their mothers [1]. More than 2 decades of research have established that Breast milk is perfectly suited to nourish infant and protect them from illness. However, there has been a worldwide decline in breast-feeding in the past few decades. A research in 1993 showed only 55.9% of Americans breast-fed their babies in the hospital. Only 19% were still breast-feeding when their babies were 6 months old [2]. The prevalence of breast feeding in Scotland is the second lowest in Europe due to ineffective interventions which seek promotion of successful Breast feeding and hospital practices which discourage and undermine breast feeding[3].

Breast feeding duration in developing countries is high but exclusive breast feeding practices are still not good. In Indonesia, Pakistan and Thailand, it is nearly 2 months and in Phillipines and Ceylon, it is 4 months[4]. These figures are influenced by so many factors among which are deficient knowledge of mothers of how to optimize health and contraceptive benefits of breast feeding. Also, demographic, socioeconomic, psychological and natural factors play an important role. Rapid expansion of milk technology with advertisement and sale of infant formula is another cause of decline of breast-feeding.

It has been found that babies given cow's milk or formula by bottle and no breast-milk have over 60% more risk of being malnourished. Almost 5 million babies each year are at risk of poor nutrition because of inadequate breast-feeding practices in rural areas [5]. And in our environment due to various factors such as unsafe water, unhygienic handling of food, storage of food at ambient tempt


for a long time and poor domestic and personal hygiene are all associated with diarrhoeal diseases which are in turn due to bottle feeding.

At the same time, young urban women are increasingly being separated from their own mothers and their female relations and thus have lost their traditional source of support and advice. Fear of adequate milk supply, nipple or breast soreness and other problems also lead to premature cessation of Breast feeding due to inadequate information on how to overcome these problems.

Therefore increased breast-feeding rates would save consumer money spent on infant formula and health care also. It could save lives as well.

The many benefits of breast-feeding include its nutritional, fertility suppressing and economic advantage as well as the psychological and health benefit to both the mother and child. Its greatest health benefit comes from the right amount of Fatty acid, lactose, water and amino acids for human digestion, brain development and growth. Breast-fed babies have fewer illnesses because human milk transfer to the infant a mother's antibody to disease. About 80% of the cells in the breast milk are macrophages, cells that kill bacteria, fungi and viruses. Breast-fed babies are protected in varying degrees, from a number of illnesses such as pneumonia, botulism, bronchitis, staph infection, influenza, ear infection and german measles. Furthermore, a mother produces antibodies to whatever disease is present in their environment, making their milk custom designed to fight the disease their babies are exposed to as well. A breast-fed baby's digestive tract contains large amount of lactobacillus bifidus, beneficial bacteria that prevent the growth of harmful organisms. Sucking at the breast promotes good jaw development as well. Nursing may have psychological benefits for the infants, creating an easy attachment between mother and child. Nursing is also nature's contraceptive. Frequent nursing suppresses ovulation or get pregnant. Lactation also stimulate the uterus to contract back to its original size.

Breast feeding is economical also. Even though a nursing mother works up a big appetite and consumes extra calories, the extra food for her is less expensive than buying formula milk for her baby. Nursing saves money while providing the best nourishment possible. To support breast feeding, various conventions and declarations have been signed and are being implemented viz. The 1990 convention on the rights of the child which is now international law where by it is a legal obligation of each state to provide mothers and families with knowledge and support required for breast feeding; the innocent declaration of August 1990 calls for the creation of an environment enabling all women to practice exclusive breast feeding for the first 4-6 months and to continue breast feeding in addition to complementary food for up to 2 years and beyond and during the world the World Summit of 1991, that was attended by 71 Head of States and Governments, women were empowered to breast feed their children for the first 4-6 months and to continue, together with complimentary food for up to the second year of life and beyond. In February 1991, the world alliance for breast feeding(WABA) was formed with the aim of mobilizing resources for the implementation of the innocent Declaration and similarly in the same year UNICEF informed manufacturers and distributors of breast milk substitutes to stop the distribution of free samples and advertising by December 1992.

It must however, be noted that Breast feeding even though good becomes insufficient for infant feeding after 6 months then adequate supplementary feeding has to be introduced from about 5 months in addition to the Breast feeding. Otherwise it leads to undernourishment and increased susceptibility to infections.

For all its health benefits, breastfeeding does have some disadvantages. In early weeks, it can be painful due to nipples becoming sore or cracked. Also, it affects woman's entire lifestyle. There are some few medical reasons why a mother shouldn't breast feed. Common illnesses such as cold, flu, skin infections, or diarrhoea, cannot be passed through breast milk but a few virus like HIV can pass through breast milk.

A few other illnesses - such as therpes, hepatitis, and Beta strept infections can be transmitted through breast milk. Silicone breast implants if leaking may harm the baby.

410 Bhavana Singh

For all its health benefits, breast feeding does have some disadvantages. In the early weeks, it can be painful. A woman's nipple may become sore or cracked. She may experience engorgement more than a bottle-feeding mother, when the breast become so full of milk they are hard and painful.

To produce enough good milk, the nursing mother needs a balanced diet that includes 500 extra calories a day and 6 to 8 glasses of fluid. She should also rest as much as possible to prevent breast infections, which are aggravated by fatigue.

Ergotamine, Bromocripine, most chemotherapy drugs for cancer, Lithium, Methotrexate. Nursing mothers should also avoid smoking. Most of these drugs cause irritability, poor sleeping pattern, vomiting, Diarrhoea in the babies. As already documented, breast milk provides the ultimate nutrition for a growing child by its many nutritional and immunological benefits which grooms the growing child’s immune response to fight infections.

Despite all these advantages, prevalence of breast feeding is declining world wide and therefore there is a need to promote, protect and support breast feeding as a child survival strategy.

In view of the above problems, this study has been done to find the baseline information about the knowledge, attitude and practices of breast feeding in our community. 1.9. Objectives of Study

General objectives To find out the knowledge, attitude and practices of breast feeding amongst women attending MCHC/CWC in Kumasi, Ashanti Region. Specific objectives

• To examine factors which affect pattern of breast feeding such as age, occupation, educational level, socio-economic status, and marutal status.

• To examine the prevalence of Exclusive breast feeding. • To find out mothers’ knowledge about the importance of breast feeding. • To examine the weaning pattern.

1.10. Basic Assumptions

• All the cases interviewed were mainly resident from Kumasi, Ashanti Region and hence were a good representatives of all women in the area.

• It is also assumed that all subjects understood clearly the objectives of the questionaire and hence answers were a true reflection of their practices.

1.11. Delimitations

• The study covered only mothers who attended CWC. • The study only covered mothers with infants in the age group 0-4 years.

1.12. Definition of Terms

Artificial feeds - all forms of infant formula feeds not including weaning preparations Supplementary feeding - introduction of solid food into child's feeding scheme

Because breast milk alone is not adequate after 5 months Weaning - The method by which a child is taken off the breast and made

accustomed to solid foods CWC - Child Welfare Clinic Weaning Diet - The food introduced during the weaning process Breast milk substitute - Any food being marketed or otherwise represented as a partial or total

replacement for breast milk


Demand feeding - Breast feeding at the child's demand or request whether or not suitable for that purpose irrespective of time

2.0. Methods of Study This study was done between June and August 1998. A total of 200 mother of infants 0-2 years were interviewed.

To conduct this study, a questionnaire was prepared to obtain the necessary information. The questionnaire was mainly of the closed type except for few open type questions which were designed to allow the mother express their ideas on certain issues.

The questionnaire was directed at ascertaining certain particulars of the mothers such as age, educational level, socio-economic status, occupation, religion, marital status, reason for coming to CWC/MCHC and their knowledge, attitude and practices of breast feeding.

A face-to-face study was done with mothers during their waiting session at the clinic. They were interviewed between 8:00am – 10:00am as it was important to get the mothers from different places in Kumasi, when they were waiting for the staffs to get ready for the days work schedule. It was also a good timing because they were all co-operative and had time to listen to advice after they had been interviewed which depended on the type of answers they gave out. They were selected randomly. They were given the correct advice after the interview and all looked very concerned and grateful. 2.2. Pretesting Questionaire

The questionnaire was protested on 20 mothers at the CWC and each mother was interviewed after the purpose of study was explained to her. There were no difficulties encountered with the questionnaire but helped to modify some few questions which were open type into closed types because the most answers fitted in different groups which was later created to simplify the questionnaire. 2.3. Analysis of Data

Most mothers interviewed were between ages 21 – 30; that is 76.07%. About 24.0% of them were either 20 or less which speaks for still large number of teenage mother in ourpopulation. From them 76.0% of the mothers were married and 24.0%were unmarried, about 79.0% were Christians by religion and 19% were Moslem and 1% Buddhist and 42.0% were traders and this not surprising as Kumasi is a commercial town. The others were Housewife 10.1%, Teachers 6.0%, Unemployed 14.0% and others 10.0% which comprised of Kenkey sellers, apprentices, groundnut, orange sellers, small scale farmers. The unemployed defines as those who re no gainfully employed and in search of jobs or those who had jobs earlier but were no more in the job.

50.0% of mothers had middle school education and 16.0% had up to primary school education. 8.0% had up to high school education and 9.0% had other training’s like Teacher Training, Commercial and Vocational School Training. 17.0% had no education at all but most could still communicate in English but with difficulty.

Economic status of the mothers which was graded based on the sources of drinking water, type of toilet facility and from an idea of monthly income. It was planned earlier to partly base our grading on the appearance in terms of dressing and behaviour at time of interview but did not gave any better grading since most mothers were dressed well and co-operated equally. Most mothers fell in the average income group which was about 39.0% of the total followed by high income group 33.0% and low income group 28.0%. This part of information was however difficult to obtain since most mothers were reluctant disclosing these information.

The parity of the mothers was also recorded. This was used to assess partly if mothers were consciously or unconsciously family planning as there was still a higher percentage of teenage mothers, 45.0% of the mothers had only one child, 26.0% of them had two children and 29.0% had three or more but less than 5.

412 Bhavana Singh

As part of the above information about parity, spacing of children was also assessed. This is necessary because if mothers do not plan spacing their pregnancies, they cannot take care of their children well. The result was quite impressive since 29.0% spaced them by more than 2 years followed by 24.0% who spaced them by an average 1½ years. Only 3.0% spaced them by less than 1 year.

The age of the Index child and this tells us that most mothers either came to the weaning centre on out patient basis or immunization or to the doctors for consultation. Only 5.0% of children were less than 1 month old. 43.0% were between 1 and 3 month and averagely 2 months followed by 24.0% who were more than 10 months but less than 2 years. About the attendance of MCHC clinic, 89.0% had been attending MCHC regularly and 11.0% had been there once or twice and have slopped attending. Table 1: Age Water Given

FREQUENCY PERCENTAGE CUM. Soon After Birth - < 1 month 76 38.0% 38.0% 1 - 3 months 46 23.0% 61.0% 4 - 6 months 36 18.0% 79.0% > months 2 1.0% 80.0% Not yet/no answer 40 20.0% 100.0%

Table 2: Mother’s Knowledge On Age Water To Be Given To Child FREQ. % CUM. SOON AFTER BIRTH - 1MTH. 32 16% 16.0% 1 – 3MONTH 18 9% 25.0% 4 – 6MONTH 134 67% 92.0% > 6 MONTH 14 7% 99.0% NOT KNOW /NO 2 1% 100.%

Table 3: Source Of Knowledge About Breast Feeding

FREQ. % CUM. ANC/CWC/ HOSPITAL HEALTH WORKERS 150 75.0% 75.0% TV. / RADIO 28 14.0% 89.0% JOURNAL / MAGAZINE NEW PAPER 8 4.0% 93.0% RELATIVES 10 5.0% 98.0% OTHERS 4 2.0% 100.0%

Table 4: Mother’s Response to Quality of Breast Milk

FREQ. % CUM. YES 200 100% 100% NUTRITIOUS NO 0 0% 100% YES 194 97.0% 97.0% HEALTHY NO 6 3.0% 100.0% YES 160 80.0% 80.0% PROTECTION FROM DISEASE NO 40 20.0% 100.0% YES 198 99.0% 99.0% ENCOURAGE BONDING NO 2 1.0% 100.0% YES 64 32.0% 32.0% CONTRACEPTIVE BENEFIT NO 76 38.0% 70.0%

OTHER 60 30.0% 100.0% YES 162 81.0% 81.0% CHEAP NO 38 19.0% 100.0%


Figure 1:

H IS T O G R A M S H O W IN G D U R A T IO N O F B R E A S T F E E D IN G

0

10

20

30

40

50

60

70

1Du ration

Perc

enta

g

< 6 m on th6 -1 2 m on th1 3 -24 m on th> 24 m on th

Figure 2:

PIE CHART SHOWING AGE OF ADDING SUPPLEMENT

10.1

34.3

21

5

29 After birth - 1month

2-4 month

5-6 month

>6 month

Not giving yet

Figure 3:

HISTO G RAM SHO W ING D IFFERENCE TYPE O F SUPPLEM ENTS G IVEN

05

1015202530354045

K oko A du lt food P ower m ilk O thers

S upplem en ts

Per

cent

age

414 Bhavana Singh

Figure 4:

HISTOGRAM SHOWING DURATION OF EXCLUSIVE BREAST FEEDING PREVIOUS CHILD

3

31

11 12

43

05

101520253035404550

1Duration

Perc

enta

ge

< 1month

1-3 month

4-6 month

> 6 month

Not know/Hasone child

Figure 5:

A PIE CHART SHOWING ROOMING IN PACTICES

62%

30%

7% 1%

Few m in-hours

24hrs - 7days

>1 - 4 weeks

>1 month

Figure 6:

H IS T O G R A M S H O W IN G K N O W L E D G E A B O U T B R E A S T F E E D IN G

0

1 0

2 0

3 0

4 0

5 0

6 0

1

K n ow led g e ab ou t b reas t feed in g

Perc

enta

ge

< 1 m o n th

1 -2 m o n th

3 -4 m o n th

5 -6 m o n th

N o t k n o w


Figure 7:

H istogram sho w ing reasons or early w ean in g

0

10

20

30

40

50

60

1R easons

Perc

enta

ge

L a ck o f Tra ditio na ls uupo rt & s e rv ic e sF e a r o f a dqua te milks upply

Nipple o f bre a s t s o re ne s s

D is like o f bre a s t fe e ding

B e c a us e o f jo b

O the rs

Figure 8:

Relation betw een age and duration of breast feeding

0

1020

3040

5060

70

<6 m onth 6-12 m onth 13-24 m onth >24 m onths

Duration

Perc

enta

ge

<20yrs

21-30yrs

Figure 9:

R e la t io ns h ip b e tw e e n m a r ita l a n d d ura t io n o f b re a s t fe e d ing

01 02 03 04 05 06 07 0

< 6m on th

6 -1 2m on th

1 3 -2 4m on th

> 2 4m on th s

D u ration

Perc

enta

ge M arr ied U m arr ied

416 Bhavana Singh

Figure 10:

Relationship between Relig ion and Duration of breast feeding

020406080

100120

<6 m onth 6-12month

13-24m onth

>24months

Duration

Per

cent

age Christian

Moslem O thers

Figure 11:

Re lations hip be tw e e n e ducational le ve l and duration of bre as t fe e d ing

010203040506070

<6 month 6-12 month 13-24month

>24months

Duration

Per

cent

age

A

B

C

D

E

Figure 12:

Relationship between occupation and duration of breast feeding

0102030405060708090

<6 month 6-12 month 13-24month

>24 months

Duration

Perc

enta

ge Teacher

Traders

Housewife

Unemployed

Others


Figure 13:

R e la t io n s h ip b e tw e e n s o c io -e c o n o m ic s ta tu s a n d d u r a t io n o f b r e a s t fe e d in g

0

1 0

2 0

3 0

4 0

5 0

6 0

7 0

< 6 m on th 6 -1 2m on th

1 3 -2 4m on th

> 2 4m on th s

D u ra tio n

Per

cent

age

L o w

A ve ra g e

H ig h

3.0. Discussion The study revealed that all mothers who came to CWC breast feed their babies. Thus the prevalence of breast feeding in Kumasi Ashanti Region is 100%. Out of 200 only 7 mothers breast fed their babies for less than 6 months. The maximum duration of breast feeding is about 13 – 24 months giving an average of 21 months and majority of mothers, 62.0%, breast fed their babies for an average 18 months.

There was not much significant relation between mother’s age and duration of breast feeding. But most women between the ages of 21 – 30 years, breast fed their babies longer than their younger ones who were either 20 years of age or less than 20 years of age.

There was a subtle relationship between educational level and duration of breast feeding mothers with primary education and middle school educational level had a similar distributions of their duration of breast feeding even though those with middle school education, a larger percentage, 60.0% breast fed for between 13 – 24 months. An average of 18 months than those with primary education. Those mothers with high school education breast fed for even more longer duration. 25% of them breast fed their babies for more than 24 months and 62.5% breast fed for an average of 18 months. Mothers who were attending or had attended Teacher’s Training School, Commercial or Vocational School or even had University, only 55.5% breast fed for an average 18 months as compared to the other educational levels it can be concluded however that mother with little or no education breast fed their babies for shorter duration of months than the more educated ones.

Religion did have very significant and relation with duration of breast feeding it is quite evident that a greater percentage of Christian mothers, 61.2% breast fed their babies for a longer duration of an average 18 months than 47.4% of Moslem mothers for the same duration.

Marital status of the women also showed differences in the duration of breast feeding 16.6% of unmarried women breast fed their babies for less than 6 months as compared to only 2.6% of married women. This is a very important finding and can be concluded that mothers who are married and settled in their lives are more stable and sound minded for a family than unmarried women.

3.6%of low economic status mothers and 15.4% of middle class mothers breast fed their babies for less than 6 months as compared to 0% of high class mothers. However 64.3% of the low class mothers breast fed for an average duration of 18 months compared to 46.1% and 54.5% of average and high class women respectively. This may be due to their inability to afford supplementary food.

With occupation and duration of breast feeding, not a single percentage of teachers, house wives, and unemployed group breast fed for less than 6 months. However, 83.3% of teachers breast fed their babies for average 18 months followed by 60.7% of other occupations which included kenkey

418 Bhavana Singh

sellers, farmers, orange sellers, 60.0% house wife, 50.0% of traders and unemployed mothers. This speaks for a better knowledge and practice among the teachers.

Most mothers(34.0%) gave supplement between ages 2 – 4 months followed by 21.0%of 5 – 6 months. About 10.0% women started giving supplement in less than a month. 29.0% of the mother’s were of parity one and had not started giving supplementary food yet. From the above figure, the percentage of early weaning is still on the higher side.

The weaning foods most commonly given was koko and weanimix, which were 25.0%. About 22.0% of mothers gave Adult food like rice and stew, yams, plantains, fufu etc. very few mothers, 13.0%, gave powdered milk or tin foods.

Mothers were asked about duration of practice of exclusive breast feeding. The question was asked about their practice on the penultimate child. There were 43.0% of mothers who had only one child and were still exclusively breast feeding them and could not contribute.

Out of 57.0%, most of the mothers 31.0% said they exclusively breast fed for an average 2 months which is a poor practice.

The most interesting part of the study is when mothers were asked about when they first breast fed their babies. This was to assess the rooming - in practice in our hospitals. 62.0% of mothers responded to breast feeding within hours and minutes and less than 24 hours.

This reflects a good picture of rooming –in practices although the reasons for not having a greater percentage still needs to be assessed. Most mothers who did not start breast feeding the first day gave reasons like the initial milk not pure and clean and some also had gone through operative procedures during their delivery after which they were sedated.

Mothers were also asked about when they first introduced water to their infants and surprisingly 38.0% of mothers gave water soon after birth and within one month of their lives.

They gave reasons like it cleanses their infants gut and helps babies gums to be cleansed from the sugary breast milk. This goes to support the fact that moll mothers in our community still have not grasped the whole rational about the importance of Exclusive breast feeding. However, most mothers (80%) practiced demand feeding.

The question of work affecting baby’s feeding schedule was not the very disappointing. Only 16% of women responded to work affecting baby’s feeding schedule whilst 82.0% of them were unaffected and said they carried their children along to their workplaces and remain to sticking to demand feeding.

Most mother (63.0%) prefer breast feeding as compared to 27.0% who prefer bottle feeding and 10% preferred both.

Most mothers (88.0%) also said their babies prefer red breast whilst 5.0% said bottle feeding and 7.0% said they preferred both.

Mothers were also assessed about their knowledge about breast feeding in terms of duration, source of knowledge, Importance of breast feeding as well as reasons for early weaning in their community. 100% answers response was received in favour of importance of breast milk for every growing child was given.

When asked about duration of Exclusive breast feeding. 51.0% of mothers responded to approximately 6months which means they have the knowledge but they do not practice it for certain reason which needs to be evaluated. The knowledge about duration of exclusive breast feeding is further supported by when water should be given to a child and 67.0% of mothers responded to an average of 5months yet the practice is still poor.

Most mothers gained their information about breast feeding from CWC/ MCHC and health workers (75.0%).

This means that health workers are doing their jobs but either there is lack of understanding among the mothers or there is lack of clarity in the knowledge that is impacted to them.

Mothers assessed on their knowledge on the quality of breast feeding, most mother said breast milk was nutritious (100%), healthier for children (97%), protects them from disease (80.0%), promotes bonding between mother and child (99%), and 81.0% agreed it was cheaper then buying


supplements. However, only 32.0% agreed it had contraceptive benefits whereas 38.0% disagreed and 30% had no idea about it. The most commonest reason for early weaning given was fear of adequate milk supply (56%) followed by Nipple of breast. 4.0. Conclusion Even though there is a world wide decline in breast feeding, the prevalence of Breast feeding in Kumasi, Ashanti Region is quite satisfactory.

In this study, although the duration of breast feeding is shorter, an average 18 months, it is hoped that this shorter duration is not the beginning of a transformation phase characterised by falling duration of feeding and reduced prevalence rates.

The trend of weaning is however greatly influenced by factors such as low educational level, socio economic status, religion, marital status and occupation. The average weaning age is 2 months which is a poor practice and this subject needs to be taught more intensively. Most mothers however weaned with wrong reason. Although their knowledge about the importance of breast feeding is good, their practices do not conform to the knowledge they seem to have.

The exact meaning of weaning is not well understood among the mothers as they do not regard water as a harmful additive to breast milk before 4 months of their babies’ lives.

However, rooming-in practices seem to be well practised in our hospitals but there is still a great percentage of defaulters. Koko and weanimix are the most common weaning food used. There is still a greater percentage of mothers who wean their babies with adult food prepared at home and that may contribute to the increased incidence of diarrhoeal diseases and malnutrition among our children as these foods are not the correct balanced diet for a growing child in that age group.

Most mothers acquired their knowledge about breast milk and breast feeding from health workers and through attendance at CWC/MCHC and the reason for their knowledge not

conforming to their practices may either be that they did not pay attention to the teaching or health workers are not doing their jobs well.

In view of the above findings, the following recommendations are being put up to help achieve a desirable attitude and to adopt better practices of breast feeding in our community: 1. Strengthening of health education, especially to young mothers and primary school girls and

middle school girls and professional mothers, which should include information especially like • Properties and component of breast milk which makes it superior to artificial feeding. • Educating mothers about the importance and duration of exclusively breast feeding for first

six months of lives of their babies. • Make a clean distinction between water being a harmful additive to their exclusive breast

feeding for the first 4-6 months and the various ways it can harm the baby. • Mothers should be encouraged to maintain to demand feeding. • Mothers should be taught to care for their breast and asked to report to the nearest hospitals

if complaints of complications of breast feeding arise. • Mothers should also be taught about when to add supplementary food to breast feeding and

also how to prepare these feeds. They should also be taught about the type of food which is of most nutritious value should be given.

The above information along with other informations like the important of antenatal care clinic and child health clinics attendance should also be stressed and should reach the mother whether through written, audio or usual media. The social and financial implication of durating from the above information should also be indicated. 2. Favourable working condition for maternity leave with full pay or a shorter working day after the

return from post natal leave. This will help reduce decline of breast feeding with skilled occupation.

420 Bhavana Singh

3. Government should make ever effort to give effect to the principles and aim of ALL articles of the international code of marketing of breasting milk substitutes which include 10 important provisions and they are:-

• No advertising of breast milk substitute to the public. • No free samples to mothers • No promotion of products in health care facilities. • No company sales representatives to advise mothers • No gifts or personal samples to health workers. • No words or pictures idealizing artificial feeding, including pictures of infants on the label

of the products • Information to health workers should be scientific and factual. • An information on artificial infant feeding, including the labels, should explain the

benefits of breast feeding and the cost and hazards associated with artificial feeding. • Unsuitable products such as sweetened condensed milk, should not be promoted for

babies. • Manufactures and distributors should comply with the code provisions even if countries

have not adopted laws or other measures. 4. As many hospitals should be made baby-friendly hospital which is thought to be the best way

achieving our goal. To become a baby friendly hospital, every facility providing maternity services and care for new born infants should

• Have a written breast feeding policy that is routinely communicated to all health care staff.

• Train all health care staff in skill necessary to implement this policy. • Inform all pregnant women about the benefits and management of breast feeding. • Help mother initiate breast feeding within a half-hour of birth. • Show mothers how to breast feed and how to maintain lactation even if they should be

separated from their infants. • Give new born infants no food or drink other than breast milk unless medically indicated. • Practice rooming-in-allow mother and infants to remain together – 24 hours a day. • Encourage breast feeding on demand. • Give no artificial teats or pacifiers to breast feeding infants. • Foster the establishment of breast feeding support groups and refer mothers to them on

discharge from hospital or clinic.


References [1] Take the baby friendly initiative, Unicef 1992. [2] UAH Research review 1995 URL: http:// www.uah.edu/res-rev/breastfeeding.html. [3] Campbell H., Jones I.; Promoting breastfeeding; a view of current position and a proposed

agenda for action in Scotland; Journal of public health medicine; 1996; 18(4); 406-414. [4] Suharyono, Paul-M.; Breastfeeding practices in Indonesia; Chung-Hua-Min-Kuo-Hsiao-Erh-

Ko-I-Hsuah-Hui-Tsa-Chih; 1997; 38(5); 338-344. [5] Robert Parker.; Unicef Beiging 1990. [6] Esmai and Songa, J.; Health education on breastfeeding in ANC in edoret district hospital,

Kenya; 1994; March, 71; 149-154. [7] Beverly Winikoff, Virginia. H. Laukaran; Breastfeeding and bottle feeding controversies in the

Developing world; Social Science and Medicine; November; 1989; 29; 859-868. [8] Rudriguez G., Scchaefer, R., Nuevos, L.; Conceptos delactancia, Su promocion yla

educacionde los profesionales dela salud; Bol of Sanit Panam; 1991; 111; 1-15. [9] Maria et al; Bulletin of PAHO; 1993; 27; 350-359 [10] Ferreira et al; Rapid epidemiologic assessment of Breastfeeding practices; Journal of Tropical

Peadiatrics; 1996; 42; 50-53. [11] Picado J.I., Oslon C.M., Rasmu ssen K.M.; A combined methodology for understanding the

duration of breastfeeding in the poor neighborhoods of mangua, Nicaragua; Rev-Panam-Salud-Publica; 1997 Dec; 2(6); 398-407.

[12] Vandale – Toney-S; Rivera-Pasquies-ME; et. al.; Breastfeeding and weaning, a survey in rural communities of Mexico; Salud – Publica – Mex; 1997 Sep, Oct; 39(5); 412-419.

[13] Catherine Staunton, Almaz Duressa et. al., Oromo immigrants and breastfeeding information for health care providers; Ethno med (Internet); www:http:Ethno med.

[14] Chye J.K. et. al.; Breastfeeding at 6 weeks and predictive factors; Journal of Tropical Paediatrics 1997; 43; 287-292.

[15] Rea M.F; Venancio – SI, Batistaa-LE; Possbility and Limitation of breastfeeding among formally employed women; Rev-Saude-Publica; April 1997; 31(2); 149 – 56.

[16] Singh M.B; Haldiya-KR; Lakshminarayan J.; Infant feeding and weaning practices in some semi-arid rural area of Rajsthan; Journal – Indian – Med – Assoc; 1997 Nov; 95(11); 576 – 8, 590.

[17] Valerie Hull, Shyam Thapa and Hadi Pratomo; Breastfeeding in the modern health sector in Indonesia; the mothers prospective; 1990; 30(5); 625 – 633.

[18] Daries – Adetugbo – AA; Adetugbo – K; Effect of early complementary feeding on nutritional status in terms infants in rural Nigeria; Nutritional Health; 1997; 12 (1); 25-31.

[19] De-Souza S.B. et. al.; Anaemia in the first year of life and its relation to breastfeeding; Rev-Saude-Publica; 1997 Feb; 31 (1); 15-20.

[20] Challacombe D.N. et. al; Changing infant feeding practices and declining incidences of Coeliac disease in West formerset; Arch-Dis-Child; 1997 Sep; 77(3); 206-9.

[21] Zeleke W. Tenssay, Aschalew Mangistu; Bacterial isolates from indigenous weaning foods in rural Ethiopian setting, Jimma Zone, South West Ethiopia, Ethiopian Medical Journal; April 1997; 35(2); 93-101.

[22] Odumodu C.V., Ighogboya I.S., Okuonghae H.O.; Performance of children on weaning foods in Jos, Nigeria; The East African Medical Journal; March 1994; 71; 155-158.

[23] Hunter M.L.; Hood C.A.; Hunter B.; Kingdom – A; Reported infant feeding, oral huyiene and dental attendance pattern in children aged 5 years and under; International Journal of Paediatrics; 1997 December, 7(4); 243 – 8.

[24] Cummiins A.G.; Thompson F.M.; Postnatal changes in mucosal immune response; Immunological cell biology; 1997 October; 5(5); 419-29.

[25] Cushing – AH, Samet-JM et al; Breastfeeding reduces risk of respiratory illness in infants; America – J-Epedemiology, 1998 May; 147 (9); 863 – 70.

422 Bhavana Singh

[26] Wright A.L., Bauer M., Naylor A.A., Sutcliffe E., Clark L.; Increasing breastfeeding rates to reduce infant illness at the community level; Paediatrics; 1998 May; 101(5); 837-44.

[27] Park M..J.; Namgung R.; Kim D.H., Tsang R.C.; Bone mineral content is not reduce despite low Vit D status in breast milk – fed infants; Journal of peadiatrics; 1998 April; 132 (4); 641 – 5.

[28] Richard M., Wadsworth M., Rahimi – Foroushani A., Hardy R., Kuh D., Paul A.; Infant nutrition and cognitive development in the first offspring of a national U. K. birth control; Dev-Med-Child-Neurol; 1998 March; 40(3); 163-7.

[29] Furman L., Minich N.M.; Hack M.; Breastfeeding of very low birth weight infants; J-Hum-Lact; 1998 Marc ; 14(1); 29-34.

[30] Ley P.; Patient Satisfaction. In : marcer D; Communicating with patient; Psychology and health series No. 4. London; Chapman and Hall, 1990; 1-30.

[31] Lumley J., Astbury J. Advice for pregnancy. In: Chalmers I, Enkin M, Kierse MJNC,; Effective care in pregnancy and child birth. Oxford; Oxford University press. 1989; 237-54.

[32] Murira N., Munjanya S.P., Zhanda J., Lindmark G.; Health education for pregnancy care in Harare, A survey in PHC; The Central African Journal of Medicine; Oct 1998; 42(10); 297-300

[33] Prenatal Breastfeeding education; Mediline 1997 Med (R) 1/95- 1/97. [34] Haider R., Kabir I., Hamadni J.D., Haabte D.; Reasons for failure of breastfeeding counselling;

Mothers perspectives in Bangladesh; Bulletin of WHO; 1997; 75(3); 191-196. [35] Angus Nicoll, Marie – Louise Newell, Eric Van Praag; Infant feeding policy and practice in the

presence of HIV – 1 infection; AIDS 1995; 9; 107 – 119