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Research Article
 

Views and Cultural Beliefs of Mothers about Breastfeeding in a Child Welfare Clinic in Calabar, Cross River State, Nigeria



E.E. Esienumoh, R.E. Ella and N.C. Udoakaebe
 
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ABSTRACT

Background and Objective: Breastfeeding is important for the optimal nourishment, immunity and growth and development of the infant. However, some personal views and cultural factors may interfere with adequate breastfeeding and therefore, inhibit its benefits. The present study aimed to identify the views and cultural beliefs of mothers about breastfeeding in a child welfare clinic in Calabar, Nigeria. Materials and Methods: A cross-sectional design was used in this study. Data were collected from 120 purposively selected breastfeeding mothers through questionnaire. Data were analyzed using descriptive statistics. Results: The mean age of mothers was 29.83 years and mean number of children was 2.77. Major views of mothers about breast feeding included that HIV-positive mothers should not practice breastfeeding (98.33%), breastfeeding causes breast sagging thus making women less attractive (91.60%) and only 48.33% had workplace support to breastfeed. All of the mothers (100%), though from different cultural backgrounds, had a common cultural belief that breast milk goes sour if mother and baby are separated for more than 1 day and consequently, breastfeeding should be discontinued. Others (42.50%) believed that breastfeeding mothers should drink plenty of palm wine or stout beer to increase milk production, some women believed that breast milk is not sufficient food for the newborn (20.83%) and only 9.17% believed that breastfed babies are unhealthy and weak. Conclusion: The views and cultural beliefs of mothers do not support optimal breastfeeding. The mothers’ views and cultural beliefs in this setting have the potential to cause infant undernutrition with negative effects on the child health, development and survival.

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  How to cite this article:

E.E. Esienumoh, R.E. Ella and N.C. Udoakaebe, 2020. Views and Cultural Beliefs of Mothers about Breastfeeding in a Child Welfare Clinic in Calabar, Cross River State, Nigeria. Pakistan Journal of Nutrition, 19: 500-506.

DOI: 10.3923/pjn.2020.500.506

URL: https://scialert.net/abstract/?doi=pjn.2020.500.506
 
Copyright: © 2020. This is an open access article distributed under the terms of the creative commons attribution License, which permits unrestricted use, distribution and reproduction in any medium, provided the original author and source are credited.

INTRODUCTION

Nature has designed that infants depend on their mother for nourishment through breastfeeding. Breast milk is specie-specific and this implies that human milk is the best for human baby. Breast milk is the perfect source of nutrition for infants, as it contains the right proportion and quantity of vitamins, protein and fat1 as well as immunoglobulins. A meta-analysis showed that breastfeeding protects infants against childhood diseases such as diarrhoea, otitis media and respiratory infections, therefore reducing hospital admissions2. Breastfeeding exclusively reduces infant mortality due to common childhood illnesses and helps quicker recovery from illness. It has been found to also reduce the risk of chronic conditions later in life, for example obesity and diabetes mellitus3. The infant, if adequately breastfed, obtains nutrients in the right proportions and is protected against specific infections through immunity acquired from the mother4,5. There is a positive correlation between intelligence quotient (IQ) with breastfeeding practices for both mother and child2,3.

Generally, studies have shown that breastfeeding is advantageous to infants, mothers, families and the society at large. These advantages include health, nutritional, immunologic, social, economic and environmental benefits5. Breastfeeding is also beneficial for mothers in several ways which include delay in return to fertility, reduction of risk of Type II diabetes Mellitus, cancers of the breast, uterus and ovaries3.

In contrast, if an infant is not adequately breastfed and therefore deprived of the benefits derived from breast milk such infant is at the risk of dying quite early in life. Mortality of children under 5 years is a global problem and with a great burden in sub-Saharan Africa, particularly, Nigeria6. World Health Organization (WHO) data showed that 5.4 million children under 5 years-old died in 2017, with neonates constituting 2.5 million of these deaths. This figure translates to about 15,000 deaths per day. The risk of such deaths is about 15 times higher in sub-Saharan Africa than in developed and high income countries7. Infant and young child malnutrition is a main predisposing factor in about 45% of all child deaths under 5 years-old. Suboptimal breastfeeding was found to be responsible for 96% of deaths in children under 12 months of age in developing countries8,9. Nonexclusively breastfed children are 15 times more likely to die from pneumonia and diarrhea than exclusively breastfed ones10,11.

Research has shown that pneumonia and diarrhea are the two leading causes of infant and child mortality, both of which are responsible for 30% of deaths among children under 5 years-old. Worldwide, India, Nigeria, Democratic Republic of Congo and Ethiopia contributed to 50% of these disease conditions8,12. Evidence has shown that optimal breastfeeding of infants below 2 years-old has the greatest impact on child survival. This has the potential of reducing mortality by 13% in children under 5 years of age in developing countries. It is also posited that more than 820,000 deaths of children under 5 years-old could be prevented every year if optimal breastfeeding were practiced for children aged 0-23 months8,13.

Apparently concerned about this tragedy in children, the UN has made provision for its reduction in its Sustainable Development Goals. Sustainable Development Goal 3 is about ensuring healthy lives and promoting wellbeing for all ages. Target 3.2 aims to end preventable deaths of newborns and children under 5 years of age by 2030, with all countries aiming to reduce neonatal and under-5 years mortality to at least as low as 12 and 25 per 1000 live births, respectively14. Several strategies have been put into place to aid in the reduction of infant mortality. One of these child survival strategies includes breastfeeding7. Evidence has shown that improving breastfeeding can save the lives of about 1.5 million children15. Furthermore, the risk of children dying before the age of 5 years is expected to decrease if optimal breastfeeding is practiced16.

Given the high rate of under-5 years mortality in sub-Saharan Africa and with Nigeria having an infant mortality rate of 70 per 1000 live births, UNICEF and WHO recommend and emphasize optimal breastfeeding as an important strategy. This high rate of mortality coupled with the fact that 45% of these deaths can be attributed to malnutrition suggests that mothers may not be breastfeeding children optimally. Several studies have examined various aspects of breastfeeding, such as exclusive breastfeeding practices as well as knowledge and attitudes of mothers towards breastfeeding. Some authors have also examined the sociocultural factors that influence breastfeeding practices. One study revealed that despite routine breastfeeding education given at antenatal and child welfare clinics, only 14.6% of mothers practiced exclusive breastfeeding17.

There is dearth of literature on personal views and cultural beliefs of mothers on breastfeeding in developing countries. These beliefs may influence their practice of optimal breastfeeding despite education on breastfeeding given at child welfare clinic. Therefore, the present study identified views and cultural beliefs of mothers about breastfeeding in a child welfare clinic in Calabar, Nigeria.

MATERIALS AND METHODS

Study design, setting and sampling: A cross-sectional descriptive study design was used to assess the views and beliefs of mothers about breastfeeding at the child welfare clinic of a health facility that is centrally located in Calabar, the capital city of Cross River State in southern Nigeria. It has a monthly attendance of about 80 to 100 mothers from various ethnic groups who bring their babies for immunization and other child health needs. This clinic is baby-friendly and gives education routinely on breastfeeding. Purposive sampling was employed to select a total of 120 breastfeeding mothers who attended the clinic during the study period.

Data collection and analysis: Data were collected through a researcher-developed questionnaire which was administered face-to-face to the mothers on clinic days over a period of 6 weeks. Questionnaires were retrieved on the spot from each mother after completion. Prior to administering the questionnaire, its validity was assessed to ensure that the items covered all research questions. The instrument was pretested in another health facility and a correlation coefficient of 0.80 was obtained. Data were analyzed through descriptive statistics using means and percentages.

Ethical consideration: Approval to carry out the study was obtained from the health facility management and informed consent was obtained from each participant following explanation of the purpose of the study and assurance that confidentiality and anonymity of data would be maintained.

RESULTS

Sociodemographic data: As shown in Table 1, the mean age was 29.83 years (range, 16-45 years). Of the women, 67.51% were married, 40.83% were civil servants and 38.33% were traders. Fifty-six (46.67%) had tertiary education followed by 48 (40.00%) with secondary education. The mean number of children was 2.77. Ethnic groups included Efik (23.33%) and Ibibio (27.50%).

Views about breastfeeding: Respondents expressed varying views about breastfeeding (Table 2). Only 58 (48.33%) said that their place of work supports breastfeeding. Also, 91.6% believed that breastfeeding causes breasts to sag. Most of the mothers (98.33%) believed that HIV-positive mothers should not breastfeed for fear of mother-to-child transmission of the disease. Only 8 (6.6%) said that their husbands discouraged breastfeeding because it interfered with their sexual relationship with their wives.

Cultural beliefs: All of the mothers (100%) held the belief that breast milk goes sour when the mother is separated from the baby for more than one day; therefore, breastfeeding should be discontinued. Fifty-one (42.50%) believed that breastfeeding mothers should drink plenty of palm wine or stout beer to increase milk production, while 20.83% believed that breast milk is not a sufficient food source for children, including newborn babies. Only 9.17% mothers stated that their babies got sick and weak because they gave only breast milk. (Table 3)

DISCUSSION

The present findings show some similarities and contradictions with other studies conducted in various settings. Aside from the normal anatomical and physiological makeup of the mother and baby, the success of breastfeeding has been found to be largely influenced by the mother’s personal resources, which include her attitude and support from various other factors comprising her social network. Several factors, including socioeconomic status, maternal level of education and beliefs related to breastfeeding, have been shown to affect the decision of mothers about breastfeeding their infants3. Other studies have also reported that structural and sociocultural factors, including a lack of knowledge and health status of mother and baby influence breastfeeding practices18-20.

The present study focused on some aspects of mothers’ resources and their social network, which were categorized into views and cultural beliefs about breastfeeding. The views, as operationalized herein, are those ideas which are not rooted in the culture of the people. For example, most of the women believed that HIV-positive mothers should not breastfeed for fear of transmission of the disease to their babies. Previously, the WHO advised that HIV-positive mothers should avoid breastfeeding if they were able to afford, prepare and store baby formula safely. However, evidence based on research has since emerged which shows that a combination of exclusive breastfeeding and use of antiretroviral treatment significantly reduces the risk of transmitting HIV to babies through breastfeeding21. Consequently, the WHO now recommends that HIV-positive mothers or their babies take antiretroviral drugs throughout the entire breastfeeding period until the baby is 12 months-old21. This contrary belief of mothers highlight the need for adequate education to improve the quality of infant nutrition.

Additionally, the belief that breastfeeding causes breast to sag is not supported by evidence22. The present study agrees with the findings of Agunbiade and Ogunleye23 who conducted a study on constraints to breastfeeding in southwestern Nigeria and found that some mothers do not breastfeed because they believe that it could make their breasts flabby or sag and unappealing to their husbands. Similarly, another study on the effect of breastfeeding on breast aesthetics revealed that breastfeeding does not adversely affect the shape of the breasts, rather several other factors caused post-pregnancy flabbiness or ptosis of the breasts. These factors included increasing maternal age and cigarette smoking, which are associated with loss of skin elasticity, higher body mass index, greater number of pregnancies and larger pre-pregnancy bra size22. There is also an obvious gap between knowledge and practice, indicating that women of reproductive age should be adequately educated on the potential causes of flabby breasts. Such education should facilitate more informed decisions regarding breastfeeding, with the ultimate goal of providing optimal nutrition to newborns and infants.

A negligible proportion of mothers had the view that breastfeeding interferes with the sexual relationship between husband and wife, causing their husbands to withhold needed support for successful breastfeeding. This viewpoint of their husbands may be due to aesthetic reasons, as discussed above; the women feared that flabby breasts would make them less attractive to their husbands23. A study in Kenya found that some men were unsupportive of their wives breastfeeding for reasons, such as breastfeeding does not concern the man, rather it is ”women’s affair”. Some husbands compete with their babies for attention from the wives to the extent that they may ask the wives to stop breastfeeding24. In this situation, unsupportive husbands should be educated about optimal breastfeeding.

The present results revealed that the mothers’ place of work also interfered with optimal breastfeeding. This has been found to be a common phenomenon in other settings as well. Indeed, some studies in Nigeria have reported that although mothers had good knowledge and were willing to breastfeed, the least amount of support came from the workplace25. Another study in Nigeria revealed that the workplace constituted a barrier to successful breastfeeding by not providing Crèche or paid maternity leave3. The latter compelled breastfeeding mothers to return to work just 6 weeks after childbirth depriving mothers and babies of an optimal breastfeeding period. Overall, the legal framework in Nigeria does not guarantee or protect the freedom of nursing mothers to breastfeed exclusively for at least 6 months as propagated by the Baby Friendly Hospital Initiative and the National Breastfeeding policy26.

Furthermore, returning to work after childbirth or maternity leave has become another reason for discontinuing breastfeeding21. The WHO observed that more women have paid jobs now and that when women went back to work after maternity leave, they altered their breastfeeding routines in order to fit in with their work schedule. To avert this challenge, it is important that workplaces comply with the Innocenti Delaration Targets 4 and 6 which state, “To enact imaginative legislation protecting breastfeeding rights of working women and establish means for its enforcement,” and “To provide women with support they require in the family, community and workplace”, respectively27.

Another set of beliefs disclosed in the present study are culturally rooted. Cultural beliefs can have a very strong influence on the life of an individual. Although they may not be based on facts/science, they are highly esteemed by people. Culture is the heritage that members of a group pass down intergenerationally. For example, a Brazilian study discovered that mothers consulted with family members other than husbands regarding decisions on breastfeeding28. Obviously, such interactions are avenues to impart cultural beliefs which may have positive or negative effects on breastfeeding. Similarly, other studies have identified several cultural factors which contribute to a low rate of exclusive breastfeeding. Traditional beliefs and pressures from families have been found to be major barriers to optimal breastfeeding23,29. All of the women in the present study across all ethnic groups believed that breast milk goes sour if the mother is separated from the baby for more than 1 day. This is an erroneous cultural belief which works against optimal nutrition of the baby, particularly the newborn. There is no scientific evidence to support that breast milk can even go sour in the human body. This belief highlights the need for more intensive breastfeeding education and best practices for women/mothers and family decision-makers.

Another myth posed by culture is the belief that breastfeeding mothers should consume plenty of palm wine or stout beer. Palm wine contains 3% alcohol and if fermented, the alcohol content increases to about 12%. It interferes with milk flow if consumed by the breastfeeding mother. Studies have shown that babies take around 20% less milk if their mothers consume alcohol. Consequently, they will need to feed more often. In fact, one study showed that palm wine reduces breast milk flow30, indicating that palm wine consumption by nursing mothers is a harmful traditional practice which demands intervention with culturally sensitive care facilitated by the education of mothers on factors that promote milk flow. Such factors include putting the baby to the breast on demand, the eating of an adequate diet by mothers, staying hydrated and getting sufficient rest/sleep. Additionally, another study confirmed that intake of alcohol inhibits the milk ejection reflex, causing a temporary decrease in milk yield31. Although they revealed a previously common belief that alcohol was beneficial during breastfeeding because it relaxed mothers, promoting lactation and milk ejection reflex and enhanced infant sleep. Apparently, there is a dearth of literature on the long-term effects of alcohol consumption during lactation. Therefore, it would be safer for mothers to comply with recommendations from healthcare authorities and abstain from alcohol consumption during breastfeeding.

Another cultural factor was the belief that breast milk is not a sufficient food source for newborn babies. This belief is highly inaccurate and creates further doubt regarding the nutritional sufficiency of breast milk. Consequently, this belief falsely implies the need to supplement with additional liquids and solids during the recommended exclusive breastfeeding period32-34. Agunbiade and Ogunleye23 also reported that older women/grandmothers put pressure on young mothers to discontinue exclusive breastfeeding and introduce semi solids or water in addition to breast milk. This is purported to make the child grow faster so that the mother can resume her economic activities early after childbirth. This finding corroborates some previous studies which have reported conflicting advices experienced by mothers regarding breastfeeding. For example, healthcare professionals educated the mothers on the adequacy of breast milk-only for infant feeding in the first 6 months, while family and friends contradicted this34,35.

The views and cultural beliefs about breastfeeding revealed in the present study are contrary to the optimal breastfeeding of the baby. The WHO delineates optimal breastfeeding as exclusive breastfeeding for the first 6 months of life followed by introduction of appropriate complementary foods and continuation of breastfeeding, if possible, for up to 2 years of age or beyond36. In view of the apparent conflicting positions on breastfeeding between scientific evidence and mothers/family, it is important for healthcare professionals to recognize the effect of cultural diversity on breastfeeding attitudes and practices and encourage only those cultural beliefs that promote breastfeeding5. As emphasized above, breastfeeding is a child survival strategy which needs to be encouraged for adequate nutrition of children, with the ultimate aim of preventing mortality in children under 5 years-old.

LIMITATIONS

The current study was carried out in a health facility with a relatively small number of breastfeeding mothers. It did not involve mothers from other settings, such as other health facilities and/or communities outside the facility, which likely would have increased the variety of views and cultural beliefs on breastfeeding.

SUGGESTION FOR FUTURE RESEARCH

In future, additional studies should be conducted in order to validate the present results using a larger/wider population of breastfeeding mothers within and outside other health facilities. Additionally, a longitudinal study should be carried out on the short- and long-term effects of palm wine and stout beer consumption on breastfeeding mothers and their babies.

RECOMMENDATION

It is recommended that in line with the WHO, healthcare professionals should be empowered to carry out problem-solving and efficient counselling of breastfeeding mothers to promote optimal breastfeeding practices. Behavior-change strategies should be the focus in breastfeeding education of breastfeeding mothers and their husbands/partners. Also, government and other employers should tangibly support breastfeeding by improvement of work conditions for mothers. This includes ensuring a mandatory 6-month paid maternity leave for all new mothers, allowing flexible work hours and provision of designated space for breastfeeding (Crèche) in the workplace.

CONCLUSION

Although the mothers have been attending the child welfare clinic and receiving routine health education on childcare, including breastfeeding, the results of the current study show that their views and cultural beliefs do not support optimal breastfeeding. This scenario portrays various inhibitions to optimal breastfeeding practices and also indicates noncompliance with education received on optimal breastfeeding as recommended by the WHO. The mothers’ views and cultural beliefs in this setting have the potential to cause infant undernutrition with negative effects on the child health, development and survival. These findings are important and should be addressed in breastfeeding education and other programs to prevent child morbidity and mortality in this and similar settings.

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