CHAPTER ONE

INTRODUCTION

1.1 Background to the Study

Breast feeding is an integral part of the reproductive process with important implications for

the health of the mother and baby (Essien and Sampson-Akpan 2018). Exclusive Breast

Feeding (EBF) is when an infant is given its entire nutrient from human breast milk and

receives no complementary food during the first six months of birth. Thereafter, infants

should receive complimentary food with continued breast feeding up to two years of age and

beyond.EBF for the first 6 months of life followed by optimal complementary feeding are

critical public health measures for reducing and preventing morbidity and mortality in young

children because breastfeeding supports infants’ immune systems and helps protect them

from chronic conditions later in life such as obesity and diabetes(Ojong, Chiotu, and

Nlumanze 2016) Breast feeding is a physiological process through which all mammals feed

their babies. Hor nby (2014) defines breast feeding as an act of feeding from the breast.

According to Makanjuola (2016) breast feeding is the best type of feeding for infants

particularly during the first six months of the child’s life; because it provides the baby with

the essential nutritional requirements when exclusively fed with the breast milk. While health

according to WHO (2012) is defined as the state of complete physical, mental and social

well-being.

Exclusive breastfeeding refers to feeding an infant with breast milk from his or her mother or

a wet nurse, or expressed breast milk without any additional solid or liquid foods, except for

oral rehydration salt, syrups of vitamins, minerals and medicines (World Health

Organization, 2018). Infants should be given exclusive breastfeeding from birth until six

months and continues up to two years, with introduction of complementary food at the age of

six months (World Health Organization, 2013; National Coordinating Committee on Food

and Nutrition, 2016).

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Research showed that babies who are breastfed exclusively for 6 months experience less

illnesses because breast milk contains nutrients and substances that protect the baby from

several infections, some chronic disease and it leads to improved cognitive development

(Hafizan, . 2014). Gastroenteritis, or the family of digestive diseases whose primary symptom

is diarrhea, occurs less often among exclusively breastfed children and is less severe when it

does occur (Clark and Bungum, 2013; Alemayehu . 2019).

According to UNICEF, 10 million deaths in under- 5 children were recorded in 2006, of

which 4 million died within the 1st month of life and half within the first 24 hours (Ekwochi,

& Ndukwu (2014).). These mortality rates could have been reduced to the barest minimum

through support to mothers to practice EBF.A Nigerian national survey done in 2008 showed

that EBF rates still remain very low (13%) (Onah , 2014). Exclusive breastfed infants are

much less likely to die from diarrhea, acute respiratory infections and other diseases. They

are healthier, have fewer hospitalizations, and lower mortality rates than formula fed infants

(Ajayi, Hellandendu and Odekunle 2015).

Globally only 38% of infants are exclusively breastfed during the first four months of life and

complimentary feeding practices are often ill timed, inappropriate and unsafe (WHO, 2002).

In Africa, breastfeeding is the normal and cultural way of feeding infants, resulting in high

rates of initiation and longer duration of breastfeeding. However, exclusive breastfeeding

tends to decline with increased age in months. According to the International Baby Food

Action Network (IBFAN) Africa Regional Office Report(2004), exclusive breastfeeding at 3-

4 months in 2000 in the region was as follows: Botswana 29.7%, Eritrea 64%, Ghana 36%,

Nigeria 17%, Lesotho 54%, Malawi 11%, Nigeria 62%, Somalia 7%, Sudan 40.8%,

Swaziland 53%, Tanzania 4.1%, Uganda 68% and Zimbabwe 2.5%. These rates compare

well with those outside Africa.

WHO recommends that infants should be exclusively breastfed for the first six months and up

to two years or beyond. Despite appropriate feeding practice is the most cost effective

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intervention to reduce child morbidity and mortality, only 38% of children less than 6 months

of age are exclusively breastfed in the developing countries (Kemi and Olurotimi, 2018 ;

Tengku, . 2015, UNICEF, 2016 Yadavannavar and Patil, 2019).

In a systematic review and meta-analysis of four observational studies from the UK and US

in 2004, Martin and colleagues showed there was no association between breastfeeding and

mortality from cardiovascular disease (Robinson and Fall, 2015). One and half million

infants’ deaths can be avoided each year by exclusive breastfeeding. Children who are

exclusively breastfed have protection from several acute and chronic diseases such as, otitis

media, respiratory tract infections, atopic dermatitis, gastroenteritis, type 2 diabetes, sudden

infant death syndrome, and obesity and asthma during childhood (Al-Akour, 2014).

Several studies have shown that mothers find it difficult to meet personal goals and to adhere

to the expert recommendations for continued and exclusive breastfeeding despite increased

rate of initiation (Whalen and Cramton, 2016). Some of the major factors that affect

exclusivity and duration of breastfeeding include breast problems such as sore nipples or

mother’s perceptions that she is producing inadequate milk (Nkala and Msuya, 2018).societal

barriers such as employment and length of maternity leave (Thurman and Allen, 2018);

inadequate breastfeeding knowledge (Cherop, Keverenge-Ettyang, and Mbagaya, 2019); lack

of familial and societal support; lack of guidance and encouragement from health care

professionals (Ku and Chow, 2016; Thurman and Allen, 2018). These factors in turn promote

the early use of breast milk substitute.

Predictors of breastfeeding and weaning practices vary between and within countries. Urban

or rural difference, age, breast problems, societal barriers, insufficient support from family,

knowledge about good breastfeeding practices, mode of delivery, health system practices, and

community beliefs have all been found to influence breastfeeding in different areas of

developing countries (Nkala and Msuya, 2011). Information on the prevalence and factors

influencing infant feeding practices is limited in Mauritius and dates back to 2006 (Grummer-

Strawn, Kalasopatan, Sungkur, and Friedman, 2011).  The breastfeeding at work is

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influenced by several social and cultural factors that influence the frequency, duration and

initiation of breastfeeding practices among mothers (19-21). Economic factors compelling

mothers to work during breastfeeding (19,21).

Socioeconomic status, race, ethnicity, employer’s attitude and other factors have been found

to affect the working mother’s choice whether or not to breastfeed, and how long she

breastfeeds her child. The cultural support for breastfeeding differs, still some societies

identify the mother as either work oriented or family oriented (mother or worker) and to

combine breastfeeding with work seems quiet struggling for working mothers. Most female

employees maintain both social roles (mother and worker) simultaneously and reported to

negotiate the boundaries on daily basis.

Cultural variations in breastfeeding can bring visible change on the effect of the usual

demographic variables on breastfeeding prevalence.

The success of EBF has been attributed to several factors such as provision of accurate

information, support to breast feeding mothers and perception (beliefs and attitude) of

mothers, (Abiona, & Heing, 2005, Edegbai, 2017). The role of the health care professional is

critical in providing women with the information they need to make them accept and practice

EBF. Edegbai (2015) reported that health information and education significantly influenced

mothers’ knowledge and practice of EBF.

1.2 Statement of the Problem

Several factors affect mother’s infant feeding choices and options, including their social

roles, availability of artificial baby milks, cultural norms and hospital birth practices. A

woman’s return to work has frequently been found to be a main contributor to the early

termination of breastfeeding. There are many issues that disrupt mother’s breastfeeding plan

at work. Commonly cited issues are lack of workplace breastfeeding facilities, lack of family

support, mother’s inadequate knowledge about breastfeeding and feeling of embarrassment.

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Working mothers often face inflexibility in the working hours, unable to find facility for

childcare at or near the workplace, lack privacy for breastfeeding, place to store breast milk

(refrigerator), limited paid maternity leave and fear over job insecurity. Almost all mothers

can breastfeed, as long as they have correct information and support from their family,

employer, health care system and society. Often healthcare providers have limited knowledge

and training on breastfeeding and breastfeeding support at work. A study described that

significant number of primary healthcare providers were unable to provide mothers with the

necessary information on breastfeeding.

As a result of the increase rate of diarrhea among breastfeeding mothers, global campaign

urges mothers to be baby friendly, however, in most developing countries of the world like

Nigeria, malnutrition is still a life threatening issue particularly among the poor and low

income earners. The most affected are babies and children under five years of age. High

mortality rates are still persisting among the babies who are not breastfed4 In Nigeria, despite

increasing level of campaign on exclusive breastfeeding, there is still a wide gap between

knowledge and practice of breast feeding since most mothers do not appreciate practicing it

appropriately.

1.3 Objectives of the Study

The general objective of the study is to analyse factors affecting the practice of exclusive

breast feeding in mothers attending Okada primary health centre. Other specific objectives of

this study are to

i. To establish the Practice of breast feeding among mothers attending Okada primary

health centre

ii. To determine whether exclusive breast feeding is practiced among mothers attending

Okada primary health centre

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 iii. To determine factors that could hinder the practice of exclusive breast feeding among

mothers attending Okada primary health centre

iv. To establish factors that could enhance exclusive breastfeeding among mothers

attending Okada primary health centre.

1.4 Research Questions

This research work shall be guided by the following research questions:

i. Do women of Okada primary health centre breastfeed their babies

ii. Is exclusive breast feeding being practiced among mothers attending Okada primary

health centre

iii. What are the possible factors that could hinder the practice of exclusive breast feeding

among mothers attending Okada primary health centre?

iv. What are the factors that could enhance exclusive breastfeeding among mothers

attending Okada primary health centre?

1.5 Hypotheses

Hypothesis One

H0: There is no significant association between the level of knowledge and the practice of

exclusive breastfeeding among mothers attending Okada primary health centre

H1: There is significant association between the level of knowledge and the practice of

exclusive breastfeeding among mothers attending Okada primary health centre

1.6 Significance of the Study

This study has generated information on factors influencing exclusive breastfeeding practices

in a poor-resource setting. The findings will be useful to the Ministry of Public Health and

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Sanitation (MOPHS) and other organizations working in child survival programmes to design

interventions to improve the practice of exclusive breastfeeding in the area and other similar

circumstances. The findings will also be useful as a contribution to the ongoing research

efforts on exclusive breastfeeding and child survival.

The findings of this study will be useful to the government, Ministry of Health and other

organizations working in child survival programme to design interventions, appropriate

foundation programs to improve and promote the practice of optimal breastfeeding in the area

and other regions. Inform health policy makers in the formulation of appropriate policies and

interventions to promote optimal breastfeeding practices hence improve the child health in

Okada district. Inform the mothers of the region about their breastfeeding practices hence

helping to promote mother and child health. Provide useful data for research for further

research on breastfeeding practices in the region and the country at large

it is foreseen that the findings of this work will be of great benefit to all mothers despite their

age in raising up healthy children, schools/students as they are expected to be contributing to

the world of knowledge for a better society, future researchers who can lay their hands on the

findings for further studies on issues that are related to EBF, and health agencies that are in

position of developing community health in this contemporary society.

Recommendations from this study if implemented will improve the level of practice and

compliance to EBF thus reduce infant mortality and morbidity. Educationally, findings from

this study will aid the nurse/midwife during counselling on antenatal visit thus increase the

practice of EBF. The study will also provide a baseline information for future researchers in

relevant topic

Identifying the barriers to exclusive breastfeeding at four weeks postpartum among

postpartum women will help physicians, nurses, and other healthcare professionals

develop targeted breastfeeding interventions on those prominent issues.

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1.7 Scope of the Study

This study focuses on the factors affecting the practice of exclusive breast feeding in mothers

attending Okada primary health centre. The study is limited to all mothers who’s babies are

within 6 months who are breastfeeding attending Okada primary health centre

1.8 Operational Definition of Terms

Breastfeeding: Breast milk (including milk expressed or from a wet nurse).

Breastfeeding duration: Duration is the length of time for any breastfeeding,

including breastfeeding through the initial stage of exclusive breastfeeding and any

period of complementary feeding until weaning (WHO, 2001).

Breastfeeding initiation: The act of breastfeeding or feeding expressed breast milk to the

newborn (WHO, 2001).

Exclusive breastfeeding is defined as the “newborn receiving only breast milk and no other

liquids or solids except for drops or syrups consisting of vitamins, minerals, or medicines”.

Cultural factors – population beliefs, norms and local myths about breastfeeding and

infant feeding practices.

Informal settlement / slum- Living conditions in which a household lacks one or more of

these conditions; access to improved water, access to improved sanitation facilities, sufficient

living area-not overcrowded, structural quality/durability of dwellings and security of tenure .

Maternal factors - education, knowledge on breastfeeding, morbidity and breast health.

Socio-economic factors - defined by income, occupation and proxy indicators such as

ownership of items.

Partial breastfeeding- an infant receives breast milk and any food or liquids including non-

human milk and formula (WHO, 2008).

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Predominant breastfeeding – an infant receives breast milk (including milk expressed from

a wet nurse) as the predominant source of nourishment and allows water and water- based

drinks, fruit juice, ritual fluids, oral rehydration salts, drops or syrups (vitamins, minerals and

medicine) (WHO, 2008).

Pre-lacteal foods – non-breast milk feeds given before breastfeeding is initiated

Post –lacteal feeds- non-breast milk fluids and foods given after breastfeeding has been

initiated

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 CHAPTER TWO

LITERATURE REVIEW

2.0 Introduction

This chapter would explore, analyze and evaluate the previous works related to this topic

under Conceptual review, Theoretical review and Empirical review. In this chapter the

literature on factors associated with exclusive breastfeeding, both locally and globally,

was reviewed. The aim was to obtain information regarding the method used in other

similar studies and the findings thereof.

2.1 Conceptual Review

2.1.1 Breastfeeding

The term “Breastfeeding” is defined based on its categorization and the individual defining it.

Breastfeeding is defined as the normal way of providing infants with nutrients for healthy

growth and development (WHO/UNICEF, 2016). Breastfeeding is the act or means of

feeding the child with breast milk directly from the mother’s breast or wet nurse or expressed

with breast milk, solid or semi-solid foods and also requires the feeding of infant with non-

human milk (UNICEF, 2015). The following are the various categorization of breastfeeding:

Exclusive Breastfeeding; Partial Breastfeeding; and Complementary Breastfeeding

The term “Exclusive breastfeeding” also referred to as continuous breastfeeding means that

the infant is fed with breast milk expressed in addition to the breastfeeding from the mother

or wet nurse, and might be supplemented with drops, syrups (vitamins, minerals, medicine),

but with the exception of any other liquid or semi foods. Infants are recommended to be

exclusively breastfed for the first six months of life by their mothers or wet nurses

(WHO/UNICEF,2016). On the other hand, “Partial Breastfeeding” unlike exclusive

breastfeeding means the feeding of infants predominantly with breast milk, which is

expressed milk from the mother or from the wet nurse. Partial breastfeeding makes allowance

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for feeding of infants with liquids which vary from water, oral hydration solution, water

based drinks, fruit, juice to drops of vitamins, minerals and medicines. Partial breastfeeding is

also referred to as predominant breastfeeding. It does not allow the feeding of infants with

any other forms of expressed breast milk other the ones mentioned above. Both exclusive

breastfeeding and partial breastfeeding make up Full Breastfeeding (WHO/UNICEF, 2015).

However, the term “complementary breastfeeding” allows the feeding of infants with

expressed breast milk as well as with solid or semi-solid foods. It permits the infant to receive

any food or liquid including non-human milk. Complementary breastfeeding allows the

feeding of the infants with other foods aside breast milk after six months of age (UNICEF,

2012).

2.1.2 Exclusive Breastfeeding Advantages

Breast milk consists of basic nutrients containing proteins, vitamins and carbohydrate.

However, presence of minerals fulfills micronutrient needs and maternal antibodies improves

the immune system inhibiting infantile infections like gastrointestinal, respiratory and skin

infections and increases physical and neurological growth of the baby. There is increased

production of hormones that are responsible for uterine contraction, preventing hemorrhage

and maternal mortality. Lactational amenorrhea is mentioned as a natural contraceptive

benefactor following exclusivity. As well, breast cancer and ovarian cancer risk prospects are

reduced among mothers who give exclusive breast milk correlates with weight loss that

preventing early cardiac morbidity and mortality (Fairbrother and Stanger-Ross 2019).

Breastfeeding is an essential measure for the prevention of malnutrition and protection

against infection in infancy (Livingstone et al., 2000). Breastfeeding is one of the oldest

practices recommended by all religions and it is the universally endorsed solution in the

prevention of early malnutrition (Dana, 2019). It is estimated that the lives of one million

infants can be saved in the developing world by promoting breastfeeding (Moreland and

Coombs, 2000). Each year more than 10 million children under the age of five years die,

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mainly from one of a short list of causes which can be prevented easily through exclusive

breastfeeding, and the majority live in low-income countries (Black et al., 2013). Millennium

development goal number 4 is to reduce child mortality by two thirds by 2015 (United

Nations Statistics Division, 2015). Under-nutrition is estimated to be the under lying cause of

53% of under five mortality (Bryce et al., 2015). Appropriate feeding practices are of the

fundamental importance for the survival, growth, development and health of infants and

young children (John, 2017). Fault feeding practices including lack of breastfeeding and early

introduction of solid foods have been reported as health risks (Uany and Solmons, 2018).

WHO and UNICEF recommends early initiation of breastfeeding (within an hour from birth),

exclusive breastfeeding for the first 6 months, followed by continued breastfeeding for 2

years or beyond, together with adequate and safe complementary foods ( WHO, 2002 and

UNICEF, 2017). WHO, 2002 reported that globally, more than half of the newborns are not

breastfed within one hour from birth, less than 40% of infants under 6 months are exclusively

breastfed and only a minority of women continue breastfeeding their children until the age of

two. The rates on infant and young child feeding: Early initiation = Proportion of children

born in the last 24 months who were put to breast within one hour of birth. Exclusive

breastfeeding = Proportion of infants 0–5 months of age who are fed exclusively with breast

milk. Continued breastfeeding at 2 years = Proportion of children 20–23 months of age who

are fed breast milk. Moreover; complementary feeding =Proportion of infants 6–8 months of

age who receive solid, semi-solid or soft foods.

2.1.3 Benefits of breastfeeding to the infant

Breast milk is a living substance that fulfills all of a baby’s nutritional and fluid requirements

in the first six months of life (Sockol, Aguayo and Clark, 2017). Infants do not need water or

other liquids such as herbal teas to maintain good hydration even in hot climates

(LINKAGES, 2014). Colostrum which is the first milk is the baby’s first immunization. It has

high levels of antibodies, vitamin A, other protective factors which strengthen the infants’

12
immune system and reduce the chances of death in the neonatal period (Kroeger, 2016) A

multi-centre cohort study done in India, Ghana and Peru between 1995 and 1997 showed that

infants who were not breastfed had a 10-fold higher risk of dying of any cause and a 3-fold

higher risk of being hospitalized for any cause compared to those who had been

predominantly breastfed (Bahl et al., 2015).

According to Venneman et al., (2019), breastfeeding reduces the risk of sudden infant death

syndrome by up to 50% at all ages through infancy while a 15-year old cohort study

hypothesized breastfeeding was associated with protection against maternally perpetrated

child maltreatment, particularly child neglect (Strathearn et al., 2019). Association between

breastfeeding and a number of chronic or non communicable diseases including allergies,

obesity, diabetes, hypertension, cancer, and Crohn’s disease have been observed by various

studies (Leon-Cava 2012). Findings of systematic reviews and meta-analyses suggest there is

a protective effect against overweight and obesity from breastfeeding; this effect is more

important against obesity than against

2.1.4 Factors influencing the practice of exclusive breastfeeding

2.1.4.1 Maternal factors

There is evidence showing that maternal characteristics such as education influence

breastfeeding practices. In Tanzania according to Shirima, Gabre-Medhin and Greiner (2011)

duration of exclusive breastfeeding is mainly associated with information and knowledge

about breastfeeding. Maternal level of education has also been reported to be positively

associated with initiation, exclusiveness and duration of breastfeeding (AL Sahab et al.,

2010; Alemayehu, Haidar and Habte, 2019) In a study by Alemayehu et al. in Ethiopia in

2005 exclusive breastfeeding was associated significantly with, current marital status, and

economical status (Alemayehu et al., 2019).

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In Nigeria limited knowledge about exclusive breastfeeding, pressure from family and friends

to introduce complementary foods and excessive demands on maternal time against other

competing responsibilities have been shown to negatively influence the practice of exclusive

breastfeeding (Ochola., 2018).

Other maternal characteristics that have shown significant associations with exclusive

breastfeeding include maternal age, higher parity and experience of breastfeeding problems.

For example in a prospective cohort study in Nigeria in 2006/2007, older maternal age and

higher parity were significantly associated with exclusive breastfeeding (Ukegbu et al., 2011)

while in Western Tanzania, Nkala and Msuya in 2010 established that women who had no

problems related to breasts were more likely to exclusively breastfeed (Nkala and Msuya,

2011). Maternal characteristics vary widely within different contexts. While there is limited

data on factors influencing exclusive breastfeeding in Nigeria, review of available literature

did not reveal any study showing the influence maternal characteristic may have on exclusive

breastfeeding in the study area.

2. 1.4.2 Socio-economic factors

According to Xu et al., (2017) mother’s return to paid employment was negatively associated

with ‘exclusive breastfeeding’ duration in china. In contrast, no association was observed

regarding, place of residence and current employment of women in a study among women

who delivered at a maternity unit in government medical college and hospital in India

(Chudasama, Amin and Parikh, 2019). While in Nigeria mothers from higher socio-economic

status were less likely to exclusively breastfeed based on ownership of television and

telephones (Ochola, 2018), in Tanzania findings of a study by Shirima et al between 1998 to

1999 showed that socio-economic factors had no significant association with exclusive

breastfeeding (Shirima, et al., 2001). However, there is no consistency in the way the factors

influence exclusive breastfeeding practices in different communities. There is therefore need

to identify factors influencing exclusive breastfeeding in different set-ups in order to develop

context specific interventions to promote exclusive breastfeeding (Ochola, 2018).

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2.1.4.3 Cultural factors
In India, the belief that mother’s milk is not ready until 2-3 days postpartum delays initiation

of breastfeeding while colostrum is generally discarded (Bandyopadhyay, 2019). Among

Lebanese women concerns that the mother could potentially harm her infant through

breastfeeding were rooted in a number of cultural beliefs among them having an inherited

inability to produce milk, having "bad milk", and transmission of abdominal cramps to

infants through breast milk (Osman, Zein and Wick, 2019).

Other obstacles to exclusive breastfeeding include the perception of insufficient breast milk,

fear of dying or becoming too sick to breastfeed, (Fjeld et al., 2018). These findings agree

with those of many studies in China (Xu et al., 2009) and in Nigeria (Ochola, 2018) which

have shown perceived breast milk insufficiency as a reason for discontinuing exclusive

breastfeeding. From most of the studies, cultural practices do not agree with exclusive

breastfeeding for 6 months. There is need to identify the cultural factors that may negatively

affect exclusive breastfeeding in different communities so that they can be addressed during

promotion of appropriate breastfeeding practices.

Breastfeeding is a two-food mechanism through which maternal and child health can be

enhanced. It nourishes the infant, protects him or her against infanthood and childhood

deadly diseases and keeps the infant safe for healthy adulthood living (Umar and Oche,

2017). Breastfeeding, if prolonged prevents unwanted pregnancy, thus serving as a maternal

health intervention (Nath, 2014; Hector, 2014; Fatoumata, 2019; Shams, 2013).A study

finding has shown that not more than 35% of infants are exclusively breastfed during their

first four month of life worldwide (Du Plessis, 2019). In 2007, World Health Organization

recommended exclusive breastfeeding as one of its primary aims of nutrition and public

health programmes worldwide. The breastfeeding practices adopted by mothers are

influenced by intention, support, confidence and self-efficacy (Meedya, Kathleen and Ashley,

15
2016). On the otherhand, according to Gibbons, (2000), intention is a formulated plan aimed

towards the attainment of a specific goal with the aid of certain instrumental actions.

Therefore, the intentions of how long a woman would breastfeed her baby depends to a large

extent on her inner’s desire to breastfeed (Meedya et al., 2016). Blyth and Creedy (2004), in a

longitudinal study of 300 Australian women discovered that mothers who intended to

breastfeed for a period of 12 months were likely to continue breastfeeding until four months

compared to mothers whose intentions were to breastfeed for less than 6 months. Also,

Breastfeeding desire of a mother could be as a result of breastfeeding intention and the

influence of people in her social network (DI Girolamo, 2015; Ogunba, 2013; Maduforo,

2013). Thus, the attitude and behaviour of mothers are sometimes influenced by their

husbands, close relatives and health care providers in their social networks (Scott, Shaker and

Reid, 2004; Swanson and Power, 2015; Ajibade, 2016).Similarly, the attitude of nursing

mother’s husband to breastfeeding is essential to women’s attitude and her breastfeeding

behaviour (Mc Grath, 2014; Scott, Shaker and Reid, 2014; Okolie, 2016; Maduforo, 2017).

In line with this, recent study findings on breastfeeding practices among nursing mothers

show that in communities of high ambient breastfeeding levels, the major changes that might

be achieved are increases in early initiation and exclusive breastfeeding practices (WHO,

2013). However, Blyth and Creedy (2014) in their studies discovers that early cessation of

breastfeeding leads to low maternal breastfeeding confidence. Dykes and Williams (2019)

findings show that the deterioration in breastfeeding confidence during postnatal period is an

important factor in the decision to cease breastfeeding. Grummer Strawn (2016), in his

research study on the influence of socio-demographic and economic factors on the

breastfeeding affirms that the mother’s childhood residence, educational attainment of

parents, age of mothers, mother’s occupation, parity, contraceptive use as well as the

presence of other siblings in the home have substantive influence on the breastfeeding

practices of mothers. Relatively, the educational attainment of mothers goes a long way to

16
influencing their breastfeeding practices than age of mothers (Duboia and Girard, 2015;

Rajesn, 2019).

Education has the most significant influence on breastfeeding duration, and higher

educational attainment has been found to be positively related with initiation and duration of

breastfeeding by mothers in most developed nations of the world (Hoddinott and Tappin,

2019). More so, Hector (2014) according to the findings that educational interventions that

encourage both prenatal and postnatal periods would serve as the most effective interventions

needed to promote and support breastfeeding among mothers. There are great possibilities in

the interaction between higher education and socio-economic status, which increases the

mother’s capability to purchase infant formula rather than practice full breastfeeding

(Hoddinott, Craige and Mclnnes 2018). Studies have shown than the duration of

breastfeeding by mothers is greatly influenced by the length of maternity leave as well as the

expected time of resumption to work by working mothers (Dennis, 2012). However, a longer

time period of up to six months of exclusive breastfeeding can be influenced by

supplementing education programmes with support from a health professional and peer

counsellor (Dennis, 2014; Awogbenja, 2016; Ogunba, 2018).

Relatively, the frequency of breastfeeding is very high among breastfeeding mothers in South

West Nigeria (Odu and Ogunlade, 2011). However, breastfeeding practices among mothers in

Nigeria are being influenced through antenatal group discussion, the presence of peer

support, particularly amongst mothers from low income groups, and maternity routines which

support mother infant contact (Fairbank, 2000; Ekanem, 2012; Maduforo, 2013). Dyson

(2016) posits that effective interventions in promoting of breastfeeding initiation and duration

have influence on the constant breastfeeding behaviour among mothers. Thus, the intention to

adhere to one form of breastfeeding practice or another has a link to the socio-cultural and

economic status of women across the world (Swanson and Power, 2015)

17
2.1.5 Benefits of Exclusive Breastfeeding
Breastfeeding is considered as one of the major public health strategies for improving infant

and child morbidity and mortality, improving maternal morbidity because of the wide range

of benefits of exclusive breastfeeding to the mother and infant (AAP, 2005; Piñeiro-Albero

et al., 2013; USBFC, 2014). The positive aspects of breastfeeding include advantages in

nutrition, promotion of infant growth, and development and improvements to social,

psychological, and educational interactions. A wide range of health benefits of exclusive

breastfeeding to the infant and mother have been well documented in various evidence-based

research studies (AAP, 2005; WHO, 2003).

Infant benefits. Exclusive breastfeeding between six months and two years old has been

associated with reducing the risk of allergic disease, obesity, type II diabetes, hypertension,

and hypercholesterolemia in the later lives of children (Godfrey, & Lawrence, 2010). There

is convincing evidence stating that the risk of occurrence of otitis media, gastroenteritis,

respiratory illness, sudden infant death syndrome, necrotizing enterocolitis, obesity, and

hypertension is decreased with exclusive breastfeeding (Al Binali, 2012). Evidence also

shows that breastfed babies have improved cognitive development and increased bonding

with the mother (Rempel & Moore, 2012). Exclusive breastfeeding has been shown to

decrease the incidence or severity of bacterial meningitis, bacteremia, diarrhea, and urinary

tract infection, late-onset sepsis in preterm babies, lymphoma, leukemia, Hodgkin’s

disease, and asthma (Kramer & Kakuma, 2012).

Maternal benefits. Exclusive breastfeeding decreases the chance of developing chronic

illnesses related to obesity and the development of ovarian and breast cancer among women

(Stevens et al., 2008). Breastfeeding reduces the incidences of postpartum bleeding,

maternal obesity by an earlier return to pre-pregnancy weight, and developing breast and

ovarian cancer (Godfrey & Lawrence, 2010). EBF provides additional emotional benefits to

18
the mother. In addition, evidence shows that EBF mothers are less likely to develop

depressive symptoms (Stuebe, Grewen, & Meltzer-Brody, 2013).

Social benefits. There is strong evidence that breastfeeding has many health benefits other

than maternal and infant and includes economic and social benefits to the family, the

healthcare system, and the employer (Ma, Brewer-Asling, & Magnus, 2013). The healthcare

costs associated with exclusive breastfeeding are reduced as breastfed infants mostly require

fewer sick care visits, prescriptions, and hospitalization (Ku & Chow, 2010). Another

notable social benefit of breastfeeding is the effect on the environment. According to Ball

and Bennett’s (2001) study findings, it was indicated that EBF will (a) decrease the demand

of artificial teats, plastic bottles, and milk powder tins; (b) reduce the levels of pollutants

released; and (c) decrease the depletion of natural resources used to produce them.

2.1.6 Maternal factors influencing breastfeeding practices among mothers.

The number of parity has shown to have significant association with optimal breastfeeding

practices (Alemayehu et al., 2017). Pressure and support from family and partner to introduce

complementary foods and excessive demands on maternal time against other competing

responsibilities have been shown to negatively influence the practice of exclusive

breastfeeding (Ochola., 2016). Other maternal factors that have shown significant

associations with exclusive breastfeeding include knowledge maternal age, mother’s health

status, experience of breastfeeding and among others. First time mothers are less likely to

initiate breastfeeding and continue to breastfeed at 6 months compared to their more

experienced counterparts (Ryan et al., 2012).

First time mothers also tend to experience more difficulty establishing breastfeeding

(Grummer-Strawn, 2018) and are more likely to report discontinuing breastfeeding because.

Parity, the mother’s experience with birth, has been shown to be an influential factor for

breastfeeding initiation and success (Ruowei et al., 2018). Primiparas, first time mothers,

19
have less self confidence in their ability to successfully breastfeed than multiparas, who have

experienced child birth and caring foran infant. Intention to breastfeed has been demonstrated

to be a strong predictor of breastfeeding initiation (Ryan et al., 2016).

However, there are conflicting findings on the impact of a mother’s attitude toward

breastfeeding and long term breastfeeding success (Parkinsonetet al., 2017). Nevertheless,

studies have found that women who have positive attitudes toward breastfeeding and a strong

determination to breastfeed long term are more likely to overcome difficulties related to

working outside of the home and successfully breastfeeding their infants (Rojjanasrirat &

Sousa, 2016). The feeding method that family and friends have used seems to influence how

each feeding method is perceived by the individual (Rojjanasrirat & Sousa, 2016).

Another individual factor is mother’s knowledge which influences the practice of optimal

breastfeeding. Globally, 60% of the infant and young child deaths occur due to inappropriate

infant feeding practices and infectious disease where two-thirds of these deaths are

attributable to sub-optimal breastfeeding practices (Tamiru etal., 2013). Poor nutrition is not

always only the result of lack of food, but it can be due to lack of knowledge about optimal

feeding practices and provision of poor quality of food. Clear-cut programs are needed

especially in developing countries to provide a basic service and support for infants and

young children to promote optimal breastfeeding (Shikur, 2018) .

In many developing countries infants and young children are most vulnerable to malnutrition

because of lack of knowledge on how to feed a child and infectious diseases. Consequently,

large numbers of children are suffering from a wide-range of malnutrition manifested in

stunted growth, wasting and micronutrient deficiencies (International Journal of Nutrition and

Food Sciences, 2018). Optimal newborn and infant feeding practices are major determinant

of short and long-term health outcomes in individuals and social development. Children who

are not breastfed properly have repeated infections, grow less and are more likely to die by

20
the age of one month than children who receive at least some breast milk (Murage et al.,

2015).

Many observational studies showed that maternal knowledge of optimal child feeding

practices like exclusive breastfeeding for six months, continued partial breastfeeding and the

timely transition to adequate complementary food is basic to deliver physiological and

economic benefits to mothers and to keep health of a child (Murage et al. 2015). The

perceived ease of breastfeeding in comparison to formula feeding also differs across different

mothers. Some women believe that formula feeding is easier because it is easier to schedule

and it eliminates concerns about appropriate infant weight gain (Rojjanasrirat & Sousa,

2018).

Some women also report that formula feeding is less embarrassing, more reassuring because

one can visually monitor how much milk an infant is eating, and is easier when someone else

has to care for the baby (Moore & Coty, 2016). Other women believe that breastfeeding is

easier, more satisfying for child and mother, healthier, more natural, more economic, and

more convenient (Moore & Coty, 2006); but that expressing milk for feeding in the mother’s

absence was more complicated than formula feeding (Holmes et al., 2019).

Breastfeeding is nearly universal, but however, large numbers of mothers, both urban and

rural areas globally, do not practice appropriate breastfeeding and complementary feeding

behavior (International Journal of Nutrition and Food Sciences 2018). In Sub- Sahara African

countries, under-five deaths is highly associated with abrupt cessation of breastfeeding and

infectious diseases, but it is closely linked to gap of knowledge on how to feed the infant

(Tamiru et al., 2015). A recent report showed that mothers early provide water, butter and

various types of food to feed their children, thereby reducing the percentage of exclusively

breastfeed and increasing the percentage of receiving complementary food at very young age

(Mihrshahi et al.,2016).

Another factor that influences perceptions of breastfeeding is concerns about mothers own

health, stress levels, diet, etc. and how these variables can impact the health of their baby if

21
they were breastfeeding as a woman’s situation is a primary determinant of successful long

term breastfeeding. A mother’s occupation can hinder her ability to use a breast pump at

work and make it more difficult to continue breastfeeding long term (Rojjanasrirat & Sousa,

2017).

A woman who works part-time is more likely to breastfeed than a woman who works full-

time although they both use most of their timing in trying to get ends meet (Salami et al.,

2016). Working mothers are just as likely to initiate breastfeeding, but have a lower rate of

exclusive long-term breastfeeding (Johnson & Esposito, 2015).

There are many issues that disrupt mother’s breastfeeding plan at work. Commonly cited

issues are lack of workplace breastfeeding facilities, lack of family support, mother’s

inadequate knowledge about breastfeeding and feeling of embarrassment (Brown, 2014;

Woods, 2013). Working mothers often face inflexibility in the working hours, unable to find

facility for childcare at or near the workplace, lack privacy for breastfeeding, place to store

breast milk (refrigerator), limited paid maternity leave and fear over job insecurity (Rivera,

2014; Bai, 2014; Allen, 2014; Armstrong, 2014; Lawrence, 2011; Domenico, 2016; Ogido,

2018). Some studies in Nigeria have shown that mothers who delivered in a health institution

designated as baby friendly are more likely to practice exclusive breastfeeding (EBF) and

breastfeed their infants for a longer time (Ogunlesi 2019).

2.1.7 The Role of the Nurse in Promoting Exclusive Breastfeeding

Nowadays the majority of births occur in hospitals where nurses are the primary health care

providers supporting women from labor and birth through discharge. Nurses play a vital role

in preparing, educating, encouraging, and supporting women to breastfeed while the mother

came at primary health care for ante natal care and follow-up; so the nurse is a cornerstone

and instrumental in facilitating, promote and support the initiation and continuation of

breastfeeding (AWHONN, 2014).

22
Nurses and other health care professionals who care for mother-infant dyads should acquire

the knowledge and demonstrate the competence needed to provide consistent and evidence-

based breastfeeding information and support throughout the preconception, prenatal, and

postpartum periods. If the health care professional does not possess the knowledge and skills

needed to provide support, consultation with or referral to a lactation specialist or other

clinical expert should be offered for all mother-infant dyads (AWHONN, 2014).

There are many competencies that promote the knowledge, skills, and attitudes that health

professionals should possess in order to help women prepare for, initiate, and sustain

breastfeeding. Also, developing academic education programs for all health care

professionals should include content on lactation (AWHONN, 2014c). All women have the

right to expect culturally sensitive breastfeeding promotion and support. Health care

providers especially nurses should strive to understand and be prepared to address cultural

issues in all aspects of breastfeeding promotion and support for the population of women

they serve.

Breastfeeding has different meanings and levels of acceptance in different cultures;

therefore, it is essential that providers explore the specific breastfeeding concerns of the

individuals with whom they are working. All women have the right to obtain information

about the benefits of breastfeeding, so that, they are able to make informed decisions

(UNICEF, 2017). Community health nurse and other health care providers should support

each woman's choice of infant nutrition by providing women with information about the

risks and benefits of various feeding options to facilitate informed decision making.

There may be certain rare instances when a woman wants to breastfeed, but is unable to or

should avoid doing so, including some women who have had breast surgery, women with

HIV infection, certain substance use disorders, untreated tuberculosis, or who are taking

medications contraindicated in breastfeeding. In these situations, women should be given

information by their nurses and encouraged to further consult with their health care

23
providers to help them make infant feeding decisions. There may be other instances where

women erroneously think that breastfeeding is contraindicated (e.g., smoking cigarettes), and

nurses should provide correct information regarding these misconceptions.

Nurses should encourage women to discuss their medications and herbal and other

nutritional supplements with a health care provider who has expertise in breastfeeding and is

knowledgeable about the interactions of prescription and over-the-counter medications and

supplements with breastfeeding (Nies and Mcewen, 2015)

If the mother chooses to or is required to formula feed instead of breastfeed, nurses should

warning her about disadvantages and health problems associated with formula feed; if she

not persuaded the community health nurse must support her to understand how to safely

prepare, feed, and store formula and bottles. Education and resources should also include

information about the risks of contamination of formula, feeding systems, and/or water

supply. Women should be advised to monitor whether a particular feeding system and/or

formula is recalled for safety or other reasons ( Nies and Mcewen, 2015).

2.1.8The influence of Early and Exclusive Breastfeeding on Infants’ Health

and Mortality
Darmstadt, Bhutta, and Cousens (2015) observe in their studies that early initiation of

breastfeeding lowers the rates of prenatal and infant mortality. Similarly, WHO (2018) report

on infant feeding shows a higher protective effect against mortality of any breastfeeding in

the first two months compared with later ages. More so, early initiation of breastfeeding (days

1-3) lowers diarrhea during infancy, and among all preventive health and nutrition, improved

breastfeeding has been discovered as such with the greatest potential to reduce both infant

and under five child mortality up to 13% (Jones and Steketee, 2016).

Exclusive breastfed infants have been found to be less vulnerable to the risk of diarrhea as

well as other respiratory infections in infants compared with those that were not exclusively

breastfed (Chantry, Howard and Auinger, 2013). Similarly, Fatoumata et al, (2019) adds that

24
the risk of morbidity is reduced by 70% when a child is exclusively breastfed. Exclusive

breastfeeding protects the baby against exposure to unsafe food or waste and thereby

promoting the survival of the infant (Zaney, 2011). Breastfeeding of infants immediately after

child’s birth is said to prevent mothers from bleeding and also protects them against the risk

of developing breast and ovarian cancers while optimal breastfeeding practices among

mothers have been identified and recommended as the bedrock of a healthy life for infant

health and child survival (Zaney, 2016).

Recently, Mazhar (2017) affirms breast milk nutrients as the appropriate replacement for the

unbalanced diets and micro-nutrients deficiencies are the major factors responsible for the

increased risk of chronic diseases and stunted growth among infants in Nigeria. Relatively,

abnormal feeding among nursing mothers has been identified as the major factor that causes

poor growth and development, reduced immunity, risk of infections and diarrhea disease,

infant constipation, alteration in glut flora among infants in Nigeria (Ademola , 2018). Also,

Bhutta and Ysuf (2017) reported a 3-fold reduction in the risk of neonatal sepsis in

exclusively breastfed compared with the partially breastfed hospitalized neonates. Similarly,

Victora CG, (2017) reported a 5-fold and a 2-fold increased risks of death from diarrhea and

respiratory infections in infants aged birth to 2 months who were given breast milk along

with supplements compared with infants who were exclusively breastfed.

The protective influence of breastfeeding is particularly high among children living in rural

settlements, particularly with those whose parents are of little or no education, and are denied

accessibility to safe drinking water and good toilet facilities (Goldberg, 2016). For instance,

in India, exclusive breastfeeding is seen traditionally as a cheap source of food for the

children, particularly in the poor households (Nath, Land, and Singh, 20164). On the other

hand, infant mortality is high in most Indian homes with very low economic status, thereby;

the delay in introduction of supplemental food comes to serve as an adoption through which

infant survival can be enhanced through exclusive breastfeeding of their children (Ravilla and

25
Minja, 2017). The reduction of infant deaths attributable to respiratory infections and diarrhea

deaths is far below the broad-based beneficial effect of exclusive breastfeeding in prevention

of infectious diseases above impact in reducing vulnerability to contaminated food that may

have been responsible for the effective protection against diarrhea deaths (Shams, 2016). The

risks of ratio of infant deaths estimates that are associated with predominant breastfeeding or

non-breastfeeding have been found to be higher for diarrhea deaths than for attributed

respiratory deaths (Shams, 2019).

Exclusive breastfeeding as against partial breastfeeding has been identified to safeguard the

infant from human immuno deficiency virus transmission from infected nursing mothers to

their babies (Cout, 2019).

According to a report by WHO (2010), exclusive breastfeeding for the first six months is

associated with a 3-4 fold lower risk of HIV transmission as risks between breastfeeding and

replacement feeding is fundamentally changed. As it recently reported by UNICEF (2012),

about 10-20% of infants born to mothers with HIV without interventions would contract the

virus through breast milk if breastfed for two years. However, the risk of postnatal HIV

transmission after six weeks of age has been estimated at around 1% per month of

breastfeeding (World Health Organization, 2016). More importantly the early initiation of

breastfeeding has been reported to influence infant survival as it reduces overall neonatal

deaths by 20% and lowers the risk of chronic diseases such as diabetes, heart diseases,

obesity, certain cancers, compared with formula feeding in infants (UNICEF, 2018).

2.2 Theoretical Review

2.2 .1 Theory of Planned Behaviour

The theory of planned behaviour propounded by Ajzen in 1988 underpins this study. This

theory according to Ajzen (1988) posits that individual behaviour is influenced by behaviour

intentions where behaviour intention is a function of individual’s attitude towards the

behaviour and subjective norms surrounding the execution of the behaviour. Relatively, the

26
choice of a mother to breastfeed her baby exclusively for a complete period of six month as

encouraged by UNICEF, ( 2012) and UNO, (2012 or partially is influenced by the intentions

of a mother and the conforming norms and values of her immediate environment. Thus,

practice of a chosen form of breastfeeding practice by a woman is dependent on the

importance that the society place on such behaviour. Ajzen, (1988) perceives behavioural

influence as the major control of human action in the society.

According to his theory of planned behaviour, man’s willingness to perform a form of

behaviour is influenced by his perceived behavioural intentions which are determined by the

perception of his ability to carry out the expected behaviour. Similarly, the choice of

breastfeeding practice by a mother is not only subjective in nature but also the impact that the

society in which she dwells imposes on or exposes her to. Similarly, the willingness of a

mother to accept or reject the exclusive breastfeeding of her baby can be linked to her age,

educational attainment, spouse’s level of education, birth interval, adequacy of health care

provider, environmental risk factors, age at first birth, occupation, employment status and

wealth quintile. Therefore, this study finds the theory of planned behaviour by Ajzen (1988)

appropriate as it links man’s behavioural intention and his actual behaviour to the society

demands from him and what he personally chooses to gain from adhering or not to the

expected behaviour.

However, the choice of a mother to exclusively breastfeed her infant child or not goes beyond

her intention or willingness as a result of her perceived benefits, rather the influence of her

social environment may have a substantive role to play here. Therefore, cultural setting,

social relationships and social environment have great influence on the pattern of

breastfeeding practices among mothers, hence, the Social Cognitive Theory needs being

discussed.

2.2.2 The Social Cognitive Theory

27
The social cognitive theory as propounded by Albert Bandura (1986) posits that learning

occurs in a social context with a dynamic and reciprocal interaction of the persons,

environment, and behaviour. It discusses human behavioural attitude in relation to the effects

influenced by personal factors, environmental factors, and continual interaction among

people in their community. Therefore, the breastfeeding practice of a mother can be

influenced by the perception and attitude of her like or peer. For example, a mother’s

perception towards family size can influence her choice of breastfeeding practices where her

peers strongly believe that full breastfeeding can be used as a method of controlling fertility.

Also, the immediate social environment where a woman resides will go a long way in

determining her choice of breastfeeding practice.

According to Albert Bandura (1986), one of the reasons that influence the behaviour of a

person is the past experiences of the individual, which most times are caused as a result of his

interaction with other members of his immediate environment. Therefore, a woman may

decide to exclusively breastfeeds her child if she concurs to the impression of the society

which supports it, or as a result of the sound health that her child stands to enjoy. Hence, a

mother may see exclusive breastfeeding as a reciprocal for the survival of her child.

On the other hand, the influence of the social environment, social relationship and cultural

setting on the choice of breastfeeding pattern adopted by mothers goes beyond the social

cognitive theory. It is obvious that a mother’s intention and willingness to exclusively

breastfeed her baby is a form of behaviour influenced by her immediate environment. Hence,

the two theories complement each other, as they explain the influence of the society, culture

and behavioural attitude on mothers’ decision as it relates to their preferred choice(s) of

breastfeeding practices.

The reviewed literatures above were limited, these studies did not clearly reveal the

association between socio-demographic characteristics of mothers and environmental risk

factors in relation to infant mortality, rather the literatures directly explained the association

28
between socio-demographic factors and infant mortality. Also, the reviewed literatures on

breastfeeding practices among mothers explored breastfeeding as a mechanism of fertility

control, prevention of bleeding, breast and ovarian cancer, rather than explaining the

influence of the association between socio-demographic variables and breastfeeding practices

on the survival of the infant child. The above limitations on the reviewed literatures have

made it imperative for this study to be done. Thus, this study established the socio-

demographic characteristics of women and breastfeeding practices as correlates of infant

morbidity and mortality which will be useful in policy formulation on infant feeding with the

view of promoting infant health and enhancing of infant survival in Nigeria.

2.3 Empirical Review

Oyewo and Taiwo (2016) explored knowledge and awareness of exclusive breastfeeding

among mothers in Lagos, Nigeria. The researchers made use of the survey method and tried

to balance responses to a 20 item questionnaire with qualitative data obtained through

sessions with 4 focus groups. The result showed high level knowledge and awareness of

exclusive breastfeeding among nursing mothers in both rural and urban areas of Lagos. This

could be attributed to the increase creation of awareness that exits in urban cities in Nigeria,

such as Lagos. In a related study conducted by Okolo, Adewunmi and Okonji (2019) to

examine current breastfeeding knowledge, attitude, and practices of mothers in five rural

communities in Toto Local Government in Nassarawa State, Nigeria, it was revealed that

although breastfeeding was widely practiced among mothers, none of their babies was

exclusively breastfed, and pre-lacteal feeds ranging from water, formula, or herbal tea were

given by all the mothers. This was an indication that the mothers had low level knowledge of

exclusive breastfeeding practice and this can affect their attitude for EBF. Successful breast

feeding depend not only on a willing mother, a healthy infant, or encouragement by medical

personnel, but also on attitude and beliefs about breast feeding developed by mothers.

Research have shown that mothers with poor knowledge of EBF exhibit negative attitude

29
about EBF and this accounts for the low rate of the practice (Nwachukwu and Nwachukwu

2017). While some mothers try to breast feed exclusively, most perceive exclusive breast

feeding to be too difficult, stereos and tasking, and so resort to feeding their babies with

infant’s formula.

Wojcicki, Gugig, Tran, Kathiravan, Holbrook and Heyman, (2015) study on early exclusive

breastfeeding and maternal attitudes towards infant feeding with new mothers at two San

Francisco hospitals, using structured interview method revealed that a high percentage

(79.8%) of mothers exclusively breastfed their infant at a period of just 1-4 days postpartum.

Mohammad,Yousef, Zouhair, &Ahmad (2006) evaluated the knowledge,attitude and practice

to breastfeeding as well as the factors associated with breastfeeding among women in the

north of Jordan,the result showed that Jordanian women had positive attitude for breast

feeding as was reflected in their thinking that breastfeeding was easier and less expensive

than feeding infant withformula, but they exhibited negative attitude towards the practice of

exclusive breastfeeding. Also Aniebue and Adioma (2016), evaluated the knowledge, beliefs

and attitude of rural Nigeria women to EBF using a sample of 200 mothers from the rural

community of Enugu –Nigeria, out of the 154 (82.4%) that have heard of EBF only 29.9%

knew the correct time for initiation of EBF. 30.5% believed that breast milk alone was not

sufficient for the 1st six months of life of an infant. 56.7% accepted the practice of exclusive

breastfeeding, only 38.5% accepted that colostrum is safe for a child. Reasons for rejecting

colostrum were chiefly because it was perceived as poisonous, dirty milk and culturally

unacceptable Certain socio demographic variables such as age, marital status, level of

education, occupation etc have been identified as barriers to the practice of Exclusive breast

feeding. The result of Ajayi, Hellaidensis and Odekunle ( 2014) study in kogi state Nigeria

revealed that mothers between the ages of 25-35 years practiced EBF more than women 15-

24yrs.

The researchers also identified mothers’ educational level as a factor that can significantly

affect the practice of EBF. The authors opined that most women who had formal education

30
reside and work in the urban areas that have baby friendly hospitals. That these women were

exposed to mass media and hand bills on EBF; these factors created awareness on the

benefits of breast feeding, resulting in acceptance and practice of EBF. Educational level also

affirmed by HBM and HPM as a factor that can influence the practice of health promoting

behavior like EBF for the infants and mothers (Rosentock 2014, Pender, Murdaugh &

Parsons 2016).

Essien and Samson –Akpan (2015) study on EBF of women in Ikot Omin Cross River State

revealed that 64% of the women who were married practiced EBF, while 8.3% not married

did not practice EBF. The result also revealed a significant relationship between marital

status and practice of EBF when the calculated x² of 27.8 was greater than critical ײ of 9.48

with 4 degree of freedom. Grastner, Morton, Lawrence & Naylor (2006) and Rosen stock

(2000), affirmed that Fathers have an important influence on maternal decision in relation to

EBF. In Africa and in Nigeria in particular, husbands play a very significant role in decision

making and overall provision for the family. They most often decide how the family income

should be spent. Hence their support to the practice of EBF is very vital. This calls for the

total involvement through awareness creation of the benefits of EBF to not only mother but

to significant others especially husbands who are the chief providers and decision makers.

However, Bhavana. (2010) study on knowledge, attitude and practice of breast feeding - a

case study of Kumasi, Ghana examined the relationship between educational level, age,

marital status and occupation and duration of breast feeding among mothers. The findings of

the study showed that: 16.6% of unmarried women breast fed their babies for less than 6

months as compared to only 2.6% of married women. Breastfeeding a baby at least once

every 2-3 hours encourages constant supply of milk and breast feeding 8 times a day tends to

facilitate copious milk supply in most women during the 1st 4 months or more after delivery.

Many employed mothers find it difficult meeting up with the above requirement of EBF, if

the nature of their job does not allow them the opportunity (Essien and Samson Akpan 2013).

Also some employers do not encourage working mothers optimal exclusive breast feeding

31
practice after the end of maternity level, because they do make provisions for nursing

mothers to have breaks to allow them to breast feed their babies.

Mohammad, et al (2016) discovered that employed women were more likely not to practice

exclusive breastfeeding compared to unemployed women. Several studies have identified

negative attitudes of health care providers and lack of social support as barriers to successful

infant feeding practices. Friendly attitude of health workers, having friends who successfully

breast feed increases the likely hood of another breast feeding.

The study of Aghaji (2017) on EBF practice and associated factors in Enugu, Nigeria,

revealed among other things that low income and family opposition especially from

grandparents hindered EBF practice. Low economic status mothers and middle class

mothers’ breast fed their babies for less than 6 months as compared to high income mothers.

In contrast the study of Scott and Binns (2016) on socio-economic factors and exclusive

breast feeding revealed that among the 215 women studied, 78% who were low income

earners practiced EBF longer than 49.4% of high income earners that had difficulty. Some

studies also report that mothers found exclusive breastfeeding to be physically strenuous and

uncomfortable. It is an established fact that EBF has yielded tremendous benefits in the

reduction of child mortality rates in Africa and Nigeria in particular. However, despite the

benefits and some improvements in child mortality rate in Africa, much still remains to be

done because neonatal mortality has remained the same or worsened in some countries.

According to UNICEF, 10 million deaths in under- 5 children were recorded in 2006, of

which 4 million died within the 1st month of life and half within the first 24 hours (Onah et

al., 2014).These mortality rates can still be reduced to the barest minimum through adherence

of mothers to EBF. A Nigerian national survey done in 2008 showed that EBF rates still

remain very low (13%) (Onah et al., 2014).

A research study conducted in the United States showed that the most significant self-

reported factors for the discontinuation of exclusive breastfeeding in the first month were (a)

the baby had trouble suckling and latching on (54%); nipples were sore, cracked, and

32
bleeding (37%); breasts were painful (29%); and breasts were overfull or engorged (24%).

Another self-reported factor was the perception of mothers that they did not have enough

milk (Li et al., 2018). Maternal characteristics such as younger maternal age, low income,

less maternal education, and unmarried status are associated with lower breastfeeding

prevalence among women (Rojjanasrirat, & Sousa, 2015; Wiener & Wiener, 2018).

Research shows that women who began prenatal care in the firsttrimester were twice as

likely to exclusively breastfeed during the early postpartum period than women who began

prenatal care after the first trimester (Tenfelde, Finnegan, & Hill, 2016). Research studies

conducted by Ahluwalia, Li, and Morrow (2018) indicated that women who had induced

labor or cesarean deliveries were less likely to initiate and continue breastfeeding compared

to women who had spontaneous vaginal deliveries.

33
 CHAPTER THREE

METHODOLOGY
3.1 Resign Design
The researcher adopted a descriptive research design in this study. A descriptive survey

attempts to identify and explain variables that exist in a given situation and to describe the

relationship that exists between these variables in order to provide a picture of a particular

phenomenon (Cooper & Schindler, 2015). Aim is to determine the impact of the variables in

relation to each other so as to present the bigger picture of the variables in a particular

situation as recommended by Churchill and Iacobucci (2017).

The respondents in the sample will be asked various questions relating to the study by means

of a standardized procedure and the answers were compared and analyzed statistically. The

descriptive research design has been chosen for this study because of nature of the project in

which case an attempt is not made to manipulate any variable but the study will be based on

the responses which will relate to historical performance and information obtained from

mothers attending Okada primary health centre.

3.2 Population

The study population included mothers with infants 6 weeks to 11 months old attending

Okada primary health centre The target population of the study was four thousand (4000)

mothers attending Okada primary health centre

3.3 Sampling Size

The sample size is very necessary for a clear understanding of the population in question.

Therefore, given the total population to be 4,000 mothers attending Okada primary health

centre. the researcher adopted the Yamane Yaro formula for finite population (Yamane,

1973). The formula is stated below as follows:

n= N

34
 1 +N(e)2

Where
N = the required sample size
N = total population
E = error margin
I = Constant

Therefore substituting in the formula

N = 4,000
2
1 + 4,000(0.05)
N = 4,000
1 + 4000(0.0025)

N = 4000
n + 10

N = 4,000
11

N = 364

3.4 Sample Technique

Convenience sampling technique was adopted to choose mothers attending Okada primary

health centre as the study sample. Sample of three hundred and sixty four (364) respondents

will be eventually drawn from the study sample using convenience sampling method. For this

study the researcher adopted the convenience simple random sampling technique. This will

be done to eliminate bias in the course of the research and to give each eligible respondents

equal chance of being enumerated considering the population of the selected areas. A sample

of three hundred and sixty four (364) respondents will be drawn randomly from mothers

attending Okada primary health centre. This will be done to eliminate bias in the course of

the research and to give each respondent equal chance of being chosen

35
3.5 Instruments for data Collection

The procedures for collection of data for this study will be by questionnaire. Only one type of

questionnaire is to be given to all the respondents. During the administration of the

questionnaires, the respondents were instructed by the researcher to mark the most suitable

answer. The researcher use a structured questionnaire as a guide for the interviews

with the respondents. This was enable the ordering the data in a chronological order from

the start.

The questionnaire employs a likert type scale with a range of 1 to 5. All the data obtained

from primary sources will be analyzed using average and percentages. Likert type scale

analysis will be used in which points are assigned to every opinion raised according to its

weight. The responses to the survey questions were analyzed and tabulated to determine

factors affecting the practice of exclusive breast feeding in mothers attending Okada primary

health centre. Hence, responses from the questionnaire were on the five point Likert-type

questions (agreed, strongly agreed, disagreed, strongly disagreed and indifferences). Scale

questions devised was structured to obtain responses that solve the hypothetical

statements, research objectives as well as research questions. The questionnaire was

broadly divided into two section sections. Section A seeks on personal data of

respondents, section B on factors affecting the practice of exclusive breast feeding in mothers

3.6 Validity of Instrument

The face validity of the instrument will be ascertained and used as the validated questionnaire

for the study. To ensure validity of the research instrument, the questionnaire was given to

colleagues and the supervisor to validate and the necessary corrections were made before

administration of the questionnaire.The questionnaire served as a valid response of the

respondents on factors affecting the practice of exclusive breast feeding in mothers attending

Okada primary health centre. It was proficiently reviewed by the supervisor who examined

the research questionnaire before it was administered to eliminate all possible errors.

36
3.7 Reliability of instrument

Reliability ensures that there is consistency in the production of the results such that another

researcher or same researcher can be able to collect the same desired information as the

original instrument intended to use in the same target population (Oson & Onen, 2015).To

achieve reliability, the sample population was clearly defined and questionnaires were strictly

filled by the respondents from attending Okada primary health centre and were administered

the same way to all respondents. Reliability analysis for testing reliability and the internal

consistency of the data items was conducted using the Cronbach’s alpha. According to

Pallant (2001), a scale of 0.70 or above is acceptable.

3.8 Method of Data Collection

Primary data was collected using questionnaire that had both structured and unstructured

questions. I used a structured questionnaire to collect my data. The variables of my

questionnaire involve age, education, location, number of living children, and religion. The

questionnaire focused on getting information on the knowledge of EBF among the mothers,

the impact of awareness programs on them and their sources of information such as media,

friends, health care workers, and family members. It also involved both open and closed

questions Quantitative data collection will be conducted using a closed or structured

questionnaire to obtain all of the required information. The questionnaires will be developed

in English.

3.9 Method of Data Analysis

Data was checked, coded, cleaned and entered into SPSS software for analysis. All the

analysis of quantitative data was done using the Statistical Package for Social Sciences

(SPSS) version 17.0. Descriptive summary statistics such as frequencies, percentages, means,

standard deviation and median were used to exclusive breast feeding in mothers attending

Okada primary health centre

37
The data that was collected was analyzed using qualitative and quantitative techniques. The

quantitative techniques employed were the frequency and percentages tables which were used

for analyzing the variables. The data obtained was analyzed using Statistical Package for

Social Sciences (SPSS) as a tool of data analysis. The data was checked, coded and keyed in

the computer. Descriptive statistics were drawn and it included measures of central

tendencies such as; means, median, mode, cross tabulations and Standard deviation.

Descriptive Statistics was used to analyse the data generated from the socio –

demographic variables. A bivariate analysis was carried which include the use of

Pearson Product Moment correlation .All the hypotheses for the study was subjected to

appropriate statistical analysis and tested at 0.05 level of significance.

3.10 Ethical Consideration

Permission to conduct the study was obtained from the management of the Okada Primary

Health Centre. The respondents were adequately informed about the study and its objectives

and their consent was obtained. Confidentiality was strictly adhered to throughout the study.

Participation was voluntarily. The research protocol was submitted to the relevant Health

Authorities, Research Units and Ethics Committees. Verbal consent was obtained from the

mothers. They were informed of their rights to choose not to participate in the study without

affecting the care their children receive from the facility; that they can withdraw anytime they

want to should they not feel comfortable with the study; that the information collected will

remain confidential and no personal information will be disclosed to any other person and

will only be utilised for the purpose of the research.

References

Adewuya, A. O., Ola, B. A., Dada, A. O., & Fasoto, O. O. (2006). Validation of the
Edinburgh Postnatal Depression Scale as a screening tool for depression in late

38
 pregnancy among Nigerian women. Journal of Psychosomatic Obstetrics &
Gynecology, 27(4), 267–272.

Agho, K., Dibley, M., Odiase, J., & Ogbonmwan, S. (2016). Determinants of exclusive
breastfeeding in Nigeria. BMC Pregnancy and Childbirth, 11(2), 1–8

Agho, K.E., Dibley, M. J., Odiase, J. I., and Ogbonmwan, S. M (2017). Determinants of
exclusive breastfeeding in Nigeria. BMC Pregnancy and Childbirth, 11:2.
http://www.biomedcentral.com/1471-2393/11/2.

Agunbiade, O. M., & Ogunleye, O. V. (2015). Constraints to exclusive breastfeeding practice

among breastfeeding mothers in Southwest Nigeria: implications for scaling up.
International Breastfeeding Journal, 7(5), 1–10.

Aidam, B. A., Perez-Escamilla, R., Lartey, A and Aidam, J. (2015). Factors associated with
exclusive breastfeeding in Accra Ghana. European journal of Clinical Nutrition;
59(6), 789-796.

Ajzen, I., & Madden, T. J. (2016). Prediction of goal-directed behavior: Attitudes, intentions,
and perceived behavioral control. Journal of Experimental Social Psychology, 22(5),
453–474.

Alemayehu, T., Haidar J. and Habte D. (2019).Determinants of exclusive breastfeeding

practices in Ethiopia. Ethiop.J.Health Dev. 23(1):12-18
Al-Sahab, B., Lanes, A., Feldman, M and Tamim, H. (2014). Prevalence and predictors of 6-
month exclusive breastfeeding among Canadian women: a national survey. BMC
Pediatrics, 10:20.

Al-Sahab, B., Tamim, H., Mumtaz, G., Khawaja, M., Khogali, M., Afifi, R., et al. (2008).
Predictors of breast-feeding in a developing country: Results of a prospective cohort
study. Public Health Nutrition, 11(12), 1350–1356.

Amosu, A. M., Degun, A.M.; Thomas, A. M. and Babalola, A. O.( 2011). A study of the
knowledge and support level of breast-feeding among the workers in formal
employment in South-Western Nigeria. Archives of Applied Science Research,
3(2):237-244.
Anderson, A. K. (2015). Determinants of Exclusive BreastfeedingAmong Low-Income Inner-
City Women. Masters Thesis.University of Connecticut.
Arifeen, S., Black, R.E., Antelman, G., Baqui, A., Caulfield, L. and Becker, S. (2011).
Exclusive breastfeeding reduces acute respiratory infections and Diarrhea deaths
among infants in Dhaka slums. Pediatrics vol. 108: 4.e67. doi:
10.1542/peds.108.4.e67.

Avery, M., Duckett, L., Dodgson, J., Savik, K., & Henly, S. J. (1998). Factors associated with
very early weaning among primiparas intending to breastfeed. Maternal and Child
Health Journal, 2(3), 167–179.

Bahl, R., Frost, C., Kirkwood, B. R., Edmond, K., Martines, J., Bhandari, N. and Arthur, P.
(2015). Infant feeding patterns and risks of death and hospitalization in the first half
of infancy: multi-centre cohort study. Bulletin of the World Health Organisation, 83:
418-426.

39
Bandyopadhyay, M. (2009). Impact of ritual pollution on lactation and breastfeeding
practices in rural west Bengal, India. International Breastfeeding Journal, vol 4: 2.
Brown, K. H., Black, R. E., Lopez de Romana, G. and Creed de Kanashiro, H. (2019). Infant
feeding practices and their relationship with diarrhea and other diseases in Huascar
(Lima) Peru. Paediatrics . 83; 31-40
Butte, N. F., Lopez-Alarcon, M.G. and Garza, C. (2017). Nutrient adequacy of exclusive
breastfeeding for term infant during the first six months of life. World Health
Organization, Geneva.

Carter, K. N., Imlach-Gunasekara, F., McKenzie, S. K., & Blakely, T. (2012). Differential
loss of participants does not necessarily cause selection bias. Australian and New
Zealand Journal of Public Health, 36(3), 218–222.

Chandrashekhar, T.S., Joshi, H.S., Binu, V.S., Shankar, P.R., Rana, M.S.and Ramachandran,
U. (2017) .Breast-feeding initiation and determinants of exclusive breast-feeding – a
questionnaire survey in an urban population of western Nepal. Public Health
Nutrition: 10(2), 192–197. DOI: 10.1017/S1368980007248475
Cherop, C.E., Kaverenge-Ettyang A.G., Mbagaya, G.M. (2019). Barriers to exclusive
breastfeeding among infants aged 0-6 months in Eldoret municipality, Kenya. East
Africa journal of Public health 6 (1): 69-72.

Chinebuah, B., & Pérez-Escamilla, R. (2011). Unplanned pregnancies are associated with
less likelihood of prolonged breast-feeding among primiparous women in Ghana.
Journal of Nutrition, 131(4), 1247–1249.

Chisenga, M., Kasonka, L., Mkasa, M., Sinkala, M., Chintu, C., Kaseba, C., Tompkins, A.,
Murray, S. and Filteau, S. (2015). Factors affecting the duration of exclusive
breastfeeding among HIV-infected and uninfected women in Lusaka Zambia.
Journal of Human lactation, vol 21 No. 3 pp 226-275. doi:
Chudasama, R.K., Amin C.D., Parikh Y.N. (2009). Prevalence of exclusive breastfeeding and
its determinants in first 6months of life: A prospective study.
Coutinho, S.B., de Lira P. I., de Carvalho Lima M and Ashworth A. (2015). A comparison of
the effect of two systems for the promotion of exclusive breastfeeding. The Lancet;
366:1094-1100.

Cox, J. L., Holden, J. M., & Sagovsky, R. (2017). Detection of postnatal depression.
Development of the 10-item Edinburgh Postnatal Depression Scale. British Journal
of Psychiatry, 150(6), 782–786.

Dhandapany, G., Bethou, A., Arunagirinathan, A. and Ananthakrishnan, S. (2018). Antenatal

counseling on breastfeeding- is it adequate? A descriptive study from Pondicherry,
India. International Breastfeeding Journal, vol. 3: 5. Doi:10.1186/1746-4358-3-5.
Diallo, F. B., Bell, L., Moutquin, J. and Garant, M.T (2009). The effects of exclusive versus
non-exclusive breastfeeding on specific infant morbidities in Conakry (Guinea). Pan
African Medical Journal, Volume 2: Issue 2.

DiGirolamo, A., Thompson, N., Martorell, R., Fein, S., & Grummer-Strawn, L. (2005).
Intention or experience? Predictors of continued breastfeeding. Health Education &
Behavior, 32(2), 208–226.

40
Dodgson, J. E., Henly, S. J., Duckett, L., & Tarrant, M. (2013). Theory of planned behavior-
based models for breastfeeding duration among Hong Kong mothers. Nursing
Research, 52(3), 148–158.

Duijts, L., Ramadhani M K, and. Moll, H A. (2019). Breastfeeding protects against

infectious diseases during infancy in industrialized countries. A systematic review.
Blackwell Publishing Ltd Maternal and Child Nutrition 5, pp. 199–210.

Dye, T. D., Wojtowycz, M. A., Aubry, R. H., Quade, J., & Kilburn, H. (2017). Unintended
pregnancy and breast-feeding behavior. American Journal of Public Health, 87(10),
1709–1711.

Fadnes, L. T., Engebretsen, I.M.S., Wamani, H., Wangisi, J., Tumwine, J. K and Tylleskar, T
(2019). Need to optimise infant feeding counselling: A cross-sectional survey among
HIV-positive mothers in Eastern Uganda BMC Pediatrics, 9:2
Fisk,C .M, Crozier S.R., Inskip H M. ,. Godfrey K.M., Cooper, C., Roberts G. C., Robinson,
S.M. and the Southampton Women’s Survey Study Group (2016). Breastfeeding and
reported morbidity during infancy: findings from the Southampton Women’s
Survey. Blackwell Publishing Ltd Maternal and Child Nutrition
Fjeld, E., Siziya, S., Bwalya, M. K., Kankasa, C., Moland, K. M., and Tylleskar, T. (2018).’
No, sister, the breast alone is not enough for my baby.’ A qualitative assessment of
potentials and barriers in the promotion of exclusive breastfeeding in Southern
Zambia. International Breastfeeding Journal, vol 3: 26. doi:10.1186/1746-4358-3-
26.

Gatti, L. (2018). Maternal perceptions of insufficient milk supply in breastfeeding. Journal of

Nursing Scholarship, 40(4), 355–363.

Gijsbers, B., Mesters, I. Knottnerus, J. A. and Van Schayck, C. P. (2018). Factors associated
with the duration of exclusive breast-feeding in asthmatic families Oxford
University Press. Health Education Research Vol .23 no.1 Pages 158–169
doi:10.1093/her/cym013

Glatting, G., Kletting, P., Reske, S. N., Hohl, K., & Ring, C. (2017). Choosing the optimal fit
function: Comparison of the Akaike information criterion and the F-test. Medical
Physics, 34(11), 4285–4292.

Greene, N., Greenland, S., Olsen, J., & Nohr, E. A. (2011). Estimating bias from loss to
follow-up in the Danish National Birth Cohort. Epidemiology, 22(6), 815–822.

Hatsu, I. E., McDoougald, D. M., and Anderson, A. K. (2018). Effect of infant feeding on
maternal body composition. International Breastfeeding Journal, vol 3: 18. doi:
10.1186/1746-4358-3-18.
Hector, D., King, L. and Web, K. (2015). Factors affecting breastfeeding practices applying a
conceptual framework. NSW Public Health Bulletin. Vol 16 No.3-4.
Henry, B.A., Nicolau, A.I.O., Americo, C.F., Ximenes, L.B., Bernheim, R.G., Oria, M.O.B.
(2010). Socio-cultural factors influencing breastfeeding practices among low-income
women in Fortaleza-caera-Brazil: a Leininger’s Sunrise model perspective.
Enfermeria Global No. 19.

41
Hromi-Fiedler, A. J., & Pérez-Escamilla, R. (2016). Unintended pregnancies are associated
with less likelihood of prolonged breast-feeding: An analysis of 18 Demographic
and Health Surveys. Public Health Nutrition, 9(03), 306–312.

Ijarotimi, O. S. (2018). Assessing exclusive breastfeeding practices, dietary intakes and body
mass index (BMI) of nursing mothers in Ekiti State of Nigeria. Nutrition Research
and Practice, 4(3), 222–228.

Iliff, P. J., Piwoz, E. G., Tavengwa, N. V., Zunguza, C. D., Marinda, E. T., Nathoo, K. J.,
Moulton, L. H., Ward, B. J., ZVITAMBO study group and Humphrey, J. H. (2005).
Exclusive breastfeeding reduces the risk of postnatal HIV-1 transmission and
increases HIV-free survival. AIDS vol 19 no. 7.
Islam, A., Naila, U. and Khan, N. A. (2011). Breastfeeding; factors involved in avoidance.
Professional Medicine Journal; 18(1): 18-23.
Ismail, T.A.T. and Sulaiman, Z. (2018). Reliability and validity of a Malay-version
questionnaire assessing knowledge of breastfeeding. Malaysian Journal of Medical
Science. 17(3): 32-39
Katzenellenbogen, J.M., Joubert, G and Abdool Karim, S.S. (2016). Epidemiology. A manual
for South Africa. Oxford University Press Southern Africa.
Kimani-Murage, E.W., Madise, N.J., Fotso, J.C. Kyobutungi, C. Mutua, M. K., Gitau, T. M.
and Yatich, N. (2016). Patterns and determinants of breastfeeding and
complementary feeding practices in urban informal settlements, Nairobi Kenya
BMC Public Health, 11:396.

Labbok, M. H. (2012). Global baby-friendly hospital initiative monitoring data: update and
discussion. Breastfeeding Medicine, 7, 210–222.

Lau, Y. (2015). Breastfeeding intention among pregnant Hong Kong Chinese women.
Maternal and Child Health Journal, 14(5), 790–798.

Mannan, I., Rahman, S. M., Sania, A., Seraji, H. R., Arifeen, S., Winch, P., et al. (2008). Can
early postpartum home visits by trained community health workers improve
breastfeeding of newborns? Journal of Perinatology, 28(9), 632–640.

Meedya, S., Fahy, K., & Kable, A. (2016). Factors that positively influence breastfeeding
duration to 6 months: A literature review. Women Birth, 23(4), 135–145.

Mihrshahi, S., Oddy, W. H., Peat, J. K. and Kabir, I. (2018). Association between infant
feeding patterns and diarrhoael and respiratory illness: A cohort study in Chittagong,
Bangladesh. International Breastfeeding Journal, vol 3: 28. doi: 10.1186/1746-
4358-3-28.
Naanyu, V. (2008).Young Mothers, First Time Parenthood and Exclusive Breastfeeding in
Kenya. African Journal of Reproductive Health Vol 12 No 3
Naser, M. H. Hamed, A.T., and. Kanoa, B. J. (2014). Breast Feeding in Relation to Health
Outcomes at Nine Months Infants in Gaza Strip. Pakistan Journal of Nutrition 10
(6): 500-504,

National Population Commission and ICF International. (2014). Nigeria Demographic and
Health Survey 2013. Abuja, Nigeria, and Rockville, Maryland, USA: NPC and ICF
International 2014.
42
Ng’andu, N. H. (2017). An empirical comparison of statistical tests for assessing the
proportional hazards assumption of Cox’s model. Statistics in Medicine, 16(6), 611–
626.

Nguyen, K. (2009). Nutrition spectrum backgrounder: select interventions and country

Nkala, T. E., & Msuya, S. E. (2011). Prevalence and predictors of exclusive breastfeeding
among women in Kigoma region, Western Tanzania: a community based cross-
sectional study. International Breastfeeding Journal, 6(1), 17.

Nkala, T.S. and Msuya, S.E. (2014). Prevalence and predictors of exclusive breastfeeding in
Kigoma region, Western Tanzania: a community based cross-sectional study.
International breastfeeding journal 6:17

Nommsen-Rivers, L. A., & Dewey, K. G. (2009). Development and validation of the infant
feeding intentions scale. Maternal and Child Health Journal, 13(3), 334–342.

Nommsen-Rivers, L. A., Cohen, R. J., Chantry, C. J., & Dewey, K. G. (2010). The Infant
Feeding Intentions scale demonstrates construct validity and comparability in
quantifying maternal breastfeeding intentions across multiple ethnic groups.
Maternal and Child Nutrition, 6(3), 220–227.

Nwankwo, B. O., & Brieger, W. R. (2017). Exclusive breastfeeding is undermined by use of

other liquids in rural southwestern Nigeria. Journal of Tropical Pediatrics, 48(2),
109–112.

Obermeyer, C. M. and Castle S. (2017). Back to nature? Historical and cross-cultural

perspectives on barriers to optimal breastfeeding. Med Athropol; 17:39-63
Ochola, S. A. (2018). Evaluation of two counseling strategies promoting exclusive
breastfeeding among HIV-negative mothers in Kibera slum, Nairobi, Kenya: A
randomized controlled trial. PhD Thesis. Stellenbosch University, Cape Town.

Ogunlesi, T. A. (2017). Maternal socio-demographic factors influencing the initiation and

exclusivity of breastfeeding in a Nigerian semi-urban setting. Maternal and Child
Health Journal, 14(3), 459–465.

Osman, H., Zein, L. And Wick, L. (2019). Cultural beliefs that may discourage breastfeeding
among Lebanese women: A qualitative analysis. International Breastfeeding
Journal, vol 4: 12..

Pérez-Escamilla, R., Segura-Millán, S., Canahuati, J., & Allen, H. (1996). Prelacteal feeds are
negatively associated with breast-feeding outcomes in Honduras. Journal of
Nutrition, 126(11), 2765–2773.

Qureshi, A. M., Oche, O. M., Sadiq, U. A., & Kabiru, S. (2016). Using community volunteers
to promote exclusive breastfeeding in Sokoto State. Nigeria. Pan Afr Med J, 10, 8.

Shirima, R., Gebre-Medhin, M. and Greiner, T. (2015). Information and socioeconomic

factors associated with early breastfeeding practices in rural and urban Morogoro,
Tanzania. Acta Paediatr 90: 936-942.
snapshots. The National Bureau of Asian Research: Centre for Health and Aging.

43
Sockol, E., Aguayo, V. and Clark, D. (2017). Protecting Breastfeeding in West and Central
Africa: 25 years Implementing the International Code of Marketing of Breast milk
substitutes. UNICEF Regional office for West and Central Africa.
Strathearn, L., Mamun, A. A., Najman, J. M., and Callaghan, M. J. (2019). Does
breastfeeding protect against substantiated child abuse and neglect? A 15-year
cohort study. Pediatrics vol.123 No. 2 pp 483-493. doi: 10.1542/peds.2007-3546.

Tamiru, D., Belachew, T., Loha, E., & Mohammed, S. (2012). Sub-optimal breastfeeding of
infants during the first six months and associated factors in rural communities of
Jimma Arjo Woreda, Southwest Ethiopia. BMC Public Health, 12(1), 363.

Tan, K. L. (2016). Factors associated with exclusive breastfeeding among infants under six
months of age in Peninsular Malaysia. International Breastfeeding journal; 6:2

Therneau, T. M., Grambsch, P. M., & Fleming, T. R. (2015). Martingale-based residuals for
survival models. Biometrika, 77(1), 147–160.

Uchendu,U.O., Ikefuna, A.N and Emodi, I. J. (2019). Factors associated with exclusive
breastfeeding among mothers seen at the University of Nigeria Teaching Hospital. S
A Journal of Child Health; VOL. 3 NO. 1.
UNICEF. (2015).1990-2015 Celebrating the Innocenti Declaration on the protection,
promotion and support of breastfeeding. Past achievements, Present challenges and
the way forward for Infant and Young Child feeding. United Nations Children’s
Fund. New York, USA.
UNICEF. (2016).Progress for children: A report card on Nutrition Number 4. United Nations
Children’s Fund. New York, USA.
UNICEF/WHO. (2016). Baby Friendly Hospital Initiative, revised, updated and expanded for
integrated care, section 1, Background and Implementation, Preliminary Version.
United Nations Children’s Fund and World Health Organisation.

Vourganti, S., Harbin, A., Singer, E. A., Shuch, B., Metwalli, A. R., & Agarwal, P. K.
(2018). Low grade micropapillary urothelial carcinoma, does it exist? Analysis of
management and outcomes from the surveillance, epidemiology and end results
(SEER) database. Journal of Cancer, 4(4), 336.

WHO (2018a). Learning from large-scale community-based programmes to improve

breastfeeding practices. World Health Organization, Geneva.
WHO. (2017). Global strategy for infants and young child feeding. World Health
Organization, Geneva.
WHO. (2018).indicators for assessing infant and young child feeding practices: conclusions
of a consensus meeting held 6-8 November 2007 in Washington D.C, USA.

44