CHAPTER ONE

INTRODUCTION

Background of the Study

Breastfeeding has long been recognized as the cornerstone of child survival, nutrition,

and development. It offers unparalleled health benefits for infants and mothers alike,

including protection against infections, enhancement of cognitive development, and

reduction in maternal and infant mortality (World Health Organization [WHO], 2020).

Exclusive breastfeeding (EBF) during the first six months of life is particularly

recommended, followed by continued breastfeeding along with complementary feeding up

to two years or beyond. However, despite its well-documented advantages, global

adherence to recommended breastfeeding practices remains suboptimal.

Globally, an estimated 44% of infants under six months of age are exclusively breastfed,

far below the WHO target of 70% by 2030 (UNICEF, 2023). In low- and middle-

income countries, breastfeeding practices are often influenced by a complex interplay of

socio-cultural norms, maternal education levels, economic conditions, and access to

healthcare information. In many African societies, cultural beliefs and traditional practices

significantly shape maternal behavior, sometimes conflicting with evidence-based

recommendations (Ogbo et al., 2017).

In Nigeria, breastfeeding is widely practiced, but the quality and duration vary

significantly by region. The Nigeria Demographic and Health Survey (NDHS, 2018)

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reported that while 97% of Nigerian children are breastfed at some point, only 29% are

exclusively breastfed for the recommended six months. This gap reflects not only

knowledge deficits among mothers but also systemic issues such as inadequate maternity

leave policies, lack of breastfeeding-friendly environments, and limited postnatal care

services. In addition, prevailing misconceptions—such as the belief that infants need

water in addition to breast milk—persist in many communities.

Rumuigbo, a semi-urban community in Obio-Akpor Local Government Area of Rivers

State, represents a microcosm of these challenges. While the community has access to

health centers and maternal care services, the breastfeeding behaviors of mothers appear

to be influenced by traditional norms, family pressures, and variable access to accurate

health information. Despite several government and non-governmental efforts to promote

breastfeeding, it is unclear whether these have translated into improved knowledge and

practices among nursing mothers in the area.

Understanding the dynamics of breastfeeding in Rumuigbo is therefore essential. By

assessing both the knowledge and actual practices of nursing mothers, this study aims to

provide a foundation for designing culturally appropriate interventions that can improve

child health outcomes in the community.

Statement of the Problem

Breastfeeding is a life-saving intervention that is simple, cost-effective, and highly

beneficial. Yet, in many parts of Nigeria, including Rumuigbo, the adoption of

appropriate breastfeeding practices remains far from ideal. Evidence suggests that while

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mothers may initiate breastfeeding, many do not adhere to the guidelines for exclusive

breastfeeding, nor do they sustain breastfeeding for the recommended duration of up to

two years (Ezeh et al., 2020). These practices often stem from a lack of knowledge

about breastfeeding benefits, cultural norms that promote early weaning or mixed feeding,

and inadequate support from family and healthcare providers.

Moreover, health education efforts are not always effectively tailored to address the

unique challenges faced by women in specific communities. In Rumuigbo, where a mix

of traditional beliefs and modern lifestyles co-exist, it is vital to identify the specific

barriers and facilitators influencing breastfeeding. The absence of local data further

hampers effective planning and evaluation of maternal and child health programs in the

area.

Without a comprehensive understanding of the level of knowledge among nursing

mothers and their actual breastfeeding behaviors, public health initiatives may fail to

achieve meaningful change. Thus, this study seeks to bridge the gap in knowledge by

exploring the breastfeeding patterns in Rumuigbo with an emphasis on both maternal

knowledge and practices.

Objectives of the Study

The general objective of this study is to assess the knowledge and practices related to

breastfeeding among nursing mothers in Rumuigbo, Rivers State.

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The specific objectives are to:

1. Assess the level of knowledge nursing mothers in Rumuigbo have regarding

recommended breastfeeding practices.

2. Identify the types and frequency of breastfeeding practices adopted by nursing mothers

in the community.

3. Examine the relationship between maternal knowledge and the adoption of appropriate

breastfeeding practices.

4. Explore the socio-cultural and economic factors that influence breastfeeding behaviors

in Rumuigbo.

Research Questions

1. What is the level of knowledge about breastfeeding among nursing mothers in

Rumuigbo?

2. What are the common breastfeeding practices observed among nursing mothers in the

community?

3. How does maternal knowledge affect actual breastfeeding behavior?

4. What socio-cultural and economic factors influence breastfeeding practices in the

community?

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Significance of the Study

This study is timely and significant for multiple reasons. First, it contributes to the

existing body of knowledge on maternal and child health in Nigeria by offering a

localized perspective. The findings will provide valuable insights for healthcare providers,

policy makers, and public health practitioners seeking to promote optimal breastfeeding

practices.

Secondly, the research has practical implications for designing targeted health education

programs that address both knowledge gaps and behavioral patterns. By identifying key

misconceptions and barriers to effective breastfeeding, the study can inform culturally

sensitive interventions that align with the realities of mothers in Rumuigbo.

Additionally, this study supports global efforts to reduce infant mortality and improve

early childhood development. Breastfeeding is a critical component of the Sustainable

Development Goals (SDGs), particularly Goal 3, which aims to ensure healthy lives and

promote well-being at all ages. By enhancing breastfeeding knowledge and practice, this

research indirectly contributes to improving maternal and child health outcomes in line

with national and international priorities.

Finally, the study may also serve as a foundation for future research on infant nutrition

and maternal care in similar communities across Nigeria and Sub-Saharan Africa.

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Scope of the Study

This study is focused on nursing mothers residing in Rumuigbo, Rivers State, who have

children aged 0 to 24 months. The scope is limited to assessing the level of knowledge

and actual breastfeeding practices among these mothers, as well as the social and cultural

influences affecting these practices. The study will not include expectant mothers,

healthcare providers, or caregivers other than the biological mothers.

Additionally, the research does not address other aspects of infant feeding such as

complementary feeding beyond 24 months or the use of infant formula. It is also limited

in its ability to generalize findings to other regions outside Rumuigbo, although it may

provide insights relevant to similar communities.

Operational Definition of Terms

Breastfeeding: The act of feeding an infant directly with milk from the mother’s breast,

either exclusively or in combination with other feeds.

Exclusive Breastfeeding (EBF): Feeding an infant only breast milk for the first six

months of life, without any other liquids or solids, not even water.

Knowledge: The awareness, understanding, and information that mothers possess regarding

breastfeeding benefits, recommendations, and best practices.

Practice: The actual breastfeeding behaviors demonstrated by mothers, including

frequency, duration, and exclusivity of breastfeeding.

Nursing Mother: A woman currently breastfeeding her child or within the period

considered appropriate for continued breastfeeding (0–24 months post

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 CHAPTER TWO

LITERATURE REVIEW

This chapter presents the review of literature that is relevant to the study under the following

sections: Conceptual review, Theoretical Framework, Empirical Review and Summary of

Literature Review.

Conceptual Review

Concept of Breastfeeding

Breastfeeding is a fundamental aspect of human reproduction and child-rearing practices

that entails the provision of nutrition from a mother to her infant through the act of

suckling at the breast. It is an age-old practice deeply rooted in human history,

transcending cultural and geographical boundaries. Breastfeeding provides the optimal

source of nutrition for infants, delivering a balance of carbohydrates, proteins, fats,

vitamins, minerals, and bioactive compounds necessary for growth and immune protection

(Ballard & Morrow, 2021). The World Health Organization (WHO, 2023) defines

breastfeeding as the ideal method of feeding infants, recommending exclusive

breastfeeding for the first six months of life, followed by the introduction of

complementary foods while continuing breastfeeding up to two years or beyond.

At its core, breastfeeding is not solely a biological process but also a complex interplay

of emotional, psychological, and social dimensions. The act fosters a unique bond

between mother and child, facilitated through physical closeness, eye contact, and skin-to-

skin interaction, which are crucial for the infant’s psychosocial development. Furthermore,

breastfeeding is a dynamic process where the composition of human milk changes to

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meet the evolving needs of the growing child. Colostrum, the first milk produced

postpartum, is rich in antibodies and immunological factors, offering the newborn critical

protection against infections (Victora et al., 2023).

Physiologically, breastfeeding is regulated by hormonal mechanisms involving prolactin

and oxytocin. Prolactin stimulates milk production in the alveoli of the mammary glands,

while oxytocin triggers the let-down reflex, allowing milk to be ejected from the breast

(Lawrence & Lawrence, 2022). The successful establishment of breastfeeding often

requires both maternal and infant readiness, support from healthcare providers, family,

and the broader community. Breastfeeding practices are influenced by a myriad of factors

including cultural beliefs, socio-economic status, maternal education, healthcare system

support, and public health policies. Cultural practices, in particular, can significantly

shape attitudes toward breastfeeding, with some traditions promoting early initiation and

exclusive breastfeeding, while others encourage prelacteal feeding or early

supplementation (Ogbo et al., 2021). Maternal knowledge and perception of breastfeeding

benefits, along with societal support systems, play critical roles in determining

breastfeeding initiation and duration rates.

Despite the well-documented benefits, global breastfeeding rates remain suboptimal. Only

about 44% of infants worldwide are exclusively breastfed for the first six months, far

below the global target of 50% set by WHO for 2025 (UNICEF, 2024). In regions like

sub-Saharan Africa, including Nigeria, breastfeeding practices are often compromised by

traditional practices, misinformation, maternal employment challenges, and inadequate

healthcare support. Addressing these barriers requires a multifaceted approach that

includes education, policy interventions, and the normalization of breastfeeding within

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societal structures. Breastfeeding is also recognized as a significant public health

intervention that contributes to achieving multiple Sustainable Development Goals (SDGs),

including improving child survival, promoting maternal health, reducing inequalities, and

mitigating environmental degradation. As such, promoting breastfeeding transcends

individual benefits, contributing to broader societal and developmental gains.

The knowledge and practices associated with breastfeeding among nursing mothers,

particularly in local communities such as Rumuigbo, Rivers State, are essential areas of

focus. Understanding these patterns offers insights into the factors influencing

breastfeeding behaviors and identifies strategies to enhance breastfeeding rates and

outcomes, thus improving the health trajectories of mothers and children alike.

Importance of Breastfeeding

Breastfeeding is universally acknowledged as a critical public health strategy with

profound implications for the health and well-being of infants, mothers, and society at

large. Its importance transcends nutritional sustenance, encompassing immunological

protection, cognitive development, psychosocial bonding, and long-term disease prevention.

The World Health Organization (WHO, 2023) and the United Nations Children's Fund

(UNICEF, 2024) emphasize that optimal breastfeeding practices are instrumental in

achieving multiple Sustainable Development Goals (SDGs), including those related to

health, education, poverty alleviation, and environmental sustainability. Understanding the

multifaceted benefits of breastfeeding provides a compelling rationale for its promotion

and support at individual, community, and national levels.

The nutritional superiority of breast milk over any alternative feeding method is

unequivocal. Human milk is specifically tailored to meet the evolving needs of the

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growing infant, providing the ideal balance of macronutrients—carbohydrates, proteins,

and fats—and micronutrients essential for healthy growth and development (Ballard &

Morrow, 2021). Beyond its nutritional components, breast milk contains numerous

bioactive factors such as immunoglobulins, lactoferrin, lysozyme, and human milk

oligosaccharides that fortify the infant’s immune system. These components not only

protect against infectious diseases in early life but also contribute to the maturation of

the immune system, providing lasting health benefits.

Breastfeeding dramatically reduces the risk of common childhood illnesses, particularly

gastrointestinal infections, respiratory tract infections, and otitis media. A meta-analysis by

Victora et al. (2023) found that breastfeeding reduces the risk of diarrhea-related deaths

by 50% and respiratory infection-related deaths by 40% in infants. These protective

effects are most pronounced in low- and middle-income countries where access to clean

water and adequate sanitation is limited. Moreover, breastfeeding has been associated

with a lower risk of sudden infant death syndrome (SIDS), with exclusively breastfed

infants having a 50% reduced risk compared to those who are formula-fed (Thompson et

al., 2022).

Cognitive development is another critical domain influenced by breastfeeding. Breastfed

children have been consistently shown to achieve higher scores on intelligence tests

compared to formula-fed peers. This advantage persists into adolescence and adulthood,

contributing to better academic performance and earning potential (Horta et al., 2023).

The neurodevelopmental benefits are attributed to specific components in breast milk,

such as long-chain polyunsaturated fatty acids (e.g., DHA and ARA), and the close

physical and emotional interactions inherent in the breastfeeding process.

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Breastfeeding also plays a preventive role against the development of chronic diseases.

Epidemiological studies indicate that breastfed individuals have a reduced risk of obesity,

type 1 and type 2 diabetes, hypertension, and hyperlipidemia later in life (Rollins et al.,

2023). The metabolic programming initiated by early nutrition through breastfeeding

influences long-term energy balance, insulin sensitivity, and lipid metabolism,

underscoring the profound, life-course impact of early feeding practices.

The benefits of breastfeeding extend significantly to mothers, encompassing physical

health, mental well-being, and economic advantages. Immediately postpartum,

breastfeeding facilitates uterine contraction and reduces postpartum hemorrhage through

oxytocin-mediated mechanisms. Regular breastfeeding is associated with prolonged

lactational amenorrhea, which serves as a natural, though not wholly reliable, form of

contraception known as the lactational amenorrhea method (LAM) (Chowdhury et al.,

2022). This birth spacing effect has positive implications for maternal and child health,

particularly in settings with limited access to modern contraceptive methods.

Long-term maternal health benefits of breastfeeding are substantial. Numerous studies

have demonstrated that women who breastfeed have a significantly reduced risk of

developing breast and ovarian cancers. A pooled analysis of 47 epidemiological studies

found that the risk of breast cancer decreases by 4.3% for every 12 months of

breastfeeding (Collaborative Group on Hormonal Factors in Breast Cancer, 2021).

Similarly, breastfeeding has been associated with lower risks of type 2 diabetes,

hypertension, cardiovascular disease, and rheumatoid arthritis (Chowdhury et al., 2022).

Psychologically, breastfeeding fosters maternal-infant bonding, enhances maternal

confidence, and reduces the risk of postpartum depression. Oxytocin release during

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breastfeeding promotes maternal behaviors that facilitate attachment and caregiving (Kim

et al., 2020). Furthermore, breastfeeding mothers report lower levels of anxiety and

stress, contributing to improved maternal mental health outcomes. These psychosocial

benefits reinforce the centrality of breastfeeding in maternal health strategies.

Economically, breastfeeding confers significant cost savings for families and healthcare

systems. Breastfeeding eliminates the need to purchase infant formula, feeding bottles,

and sterilization equipment, thus reducing household expenditures (WHO, 2023). At the

societal level, the prevention of infant and maternal illnesses associated with suboptimal

breastfeeding translates into reduced healthcare costs and economic productivity gains.

UNICEF (2024) estimates that suboptimal breastfeeding results in global economic losses

of approximately $302 billion annually due to healthcare costs and lost productivity.

The socio-economic advantages of breastfeeding extend beyond immediate health

outcomes to broader societal development indicators. By promoting optimal early

childhood nutrition, breastfeeding contributes to the development of human capital. Higher

intelligence quotient (IQ) scores associated with breastfeeding translate into better

educational attainment, higher earning potential, and greater economic productivity in

adulthood (Horta et al., 2023). These outcomes, in turn, contribute to national economic

growth and poverty reduction. In low- and middle-income countries such as Nigeria,

where the burden of childhood malnutrition and infectious diseases is high, breastfeeding

serves as a cost-effective intervention to improve child survival rates and foster socio-

economic development (NPC & ICF, 2023). Exclusive and continued breastfeeding can

prevent a significant proportion of under-five mortality, reduce hospital admissions, and

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enhance school readiness, thus laying the foundation for healthier, more productive

societies.

Breastfeeding also promotes gender equality and women's empowerment. By reducing

child mortality and morbidity, breastfeeding enables women to participate more fully in

educational and economic opportunities. Workplace policies that support breastfeeding

mothers, such as paid maternity leave and breastfeeding-friendly environments, further

enhance women's participation in the workforce and contribute to broader gender equity

goals (Rollins et al., 2023). At the population level, breastfeeding has far-reaching public

health impacts that extend well beyond infancy. By reducing the incidence of chronic

diseases such as obesity, diabetes, and cardiovascular disease, breastfeeding contributes to

the long-term reduction of non-communicable disease burdens. This, in turn, alleviates the

strain on healthcare systems and enhances the sustainability of public health

infrastructures.

Breastfeeding is also integral to achieving multiple Sustainable Development Goals

(SDGs). It directly supports SDG 2 (Zero Hunger) by ensuring food security for infants;

SDG 3 (Good Health and Well-being) by promoting maternal and child health; SDG 4

(Quality Education) through its impact on cognitive development; and SDG 13 (Climate

Action) by reducing the environmental footprint associated with formula production and

consumption (UNICEF, 2024). Thus, breastfeeding is not merely a personal health choice

but a societal imperative with wide-ranging implications for global development.

In environmental terms, breastfeeding represents a sustainable feeding option that

generates minimal waste and requires no energy inputs for manufacturing, packaging, or

transportation. In contrast, the production of infant formula contributes to greenhouse gas

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emissions, deforestation, and water depletion. A recent analysis by Smith (2022) estimates

that universal breastfeeding could save approximately 95–153 million tonnes of CO₂

equivalent per year, highlighting its critical role in climate change mitigation strategies.

Finally, breastfeeding supports the intergenerational transmission of health. Mothers who

breastfeed are more likely to breastfeed subsequent children, creating a positive cycle of

health behaviors across generations. The knowledge and attitudes surrounding

breastfeeding are often transmitted within families and communities, reinforcing cultural

norms that prioritize maternal and child health.

Factors Influencing Breastfeeding Knowledge and Practices

Breastfeeding knowledge and practices among nursing mothers are shaped by a complex

interplay of personal, socio-cultural, economic, and healthcare system factors.

Understanding these influences is crucial for designing effective interventions aimed at

improving breastfeeding outcomes, especially in communities like Rumuigbo, Rivers State.

The following sections delve into the key determinants of breastfeeding behaviors among

mothers.

Maternal Knowledge and Education

Maternal knowledge and education significantly impact breastfeeding practices. Numerous

studies have established that mothers with higher levels of education are more likely to

initiate breastfeeding early, exclusively breastfeed for the recommended six months, and

continue breastfeeding up to two years (Victora et al., 2023; Agho et al., 2022).

Educated mothers are often better informed about the health benefits of breastfeeding

more receptive to public health messaging, and more confident in navigating

breastfeeding challenges.

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Knowledge about the correct techniques of latching, positioning, the importance of

colostrum, and the signs of adequate milk intake empowers mothers to breastfeed

successfully. Conversely, misconceptions about breastfeeding, such as beliefs that

colostrum is dirty or that breast milk alone is insufficient, often lead to prelacteal

feeding and early supplementation, thereby undermining exclusive breastfeeding efforts

(Ogbo et al., 2021). Formal antenatal education, peer counseling, and community-based

breastfeeding support groups play pivotal roles in enhancing maternal knowledge. In

Nigeria, however, gaps in breastfeeding education persist, particularly in rural and peri-

urban areas where access to skilled healthcare providers and evidence-based information

is limited (NPC & ICF, 2023). Addressing these educational gaps is critical for

promoting optimal breastfeeding practices.

Cultural Beliefs and Practices

Cultural beliefs and traditions exert a profound influence on breastfeeding behaviors. In

many African societies, including Nigeria, cultural norms dictate infant feeding practices,

often overriding biomedical recommendations. Traditional beliefs may promote early

introduction of water, herbal concoctions, or solid foods based on the perception that

breast milk alone is insufficient to meet the infant’s needs (Adedokun et al., 2022).

Some cultures view breastfeeding as a public act that should be concealed, thus

discouraging mothers from breastfeeding in public places, which can limit breastfeeding

frequency and duration.

Conversely, in some cultures, breastfeeding is highly valorized and seen as a marker of

good motherhood and familial responsibility. In such settings, mothers receive strong

support from family members, particularly grandmothers and older female relatives, who

15
often serve as primary advisors on breastfeeding matters. While such support can be

beneficial, it can also perpetuate harmful practices if the advice given is not aligned with

current evidence-based guidelines. In Rumuigbo and similar communities, it is essential to

engage cultural gatekeepers, including traditional birth attendants, religious leaders, and

elder women, in breastfeeding promotion efforts. Culturally sensitive interventions that

respect and incorporate positive traditional beliefs while correcting misconceptions can

significantly enhance breastfeeding outcomes.

Socio-economic Factors

Socio-economic status is another critical determinant of breastfeeding practices. Mothers

from higher-income households are generally more likely to access healthcare services,

receive breastfeeding education, and afford maternity leave, all of which support

successful breastfeeding. However, paradoxically, in some contexts, wealthier mothers may

be more inclined toward formula feeding due to perceptions of modernity, convenience,

or the influence of aggressive formula marketing (Rollins et al., 2023).

Employment and workplace conditions also heavily influence breastfeeding practices.

Mothers engaged in formal employment, particularly without supportive maternity leave

policies, often face challenges in maintaining exclusive breastfeeding. Lack of

breastfeeding-friendly workplace facilities, such as lactation rooms or flexible working

hours, contributes to early weaning or mixed feeding (UNICEF, 2024).

Economic constraints at the household level can also impact breastfeeding behaviors. In

low-resource settings, exclusive breastfeeding may be perceived as economically

advantageous due to the high cost of infant formula. Nevertheless, poverty-related factors

16
such as maternal malnutrition, lack of social support, and the need to return to work

shortly after delivery can undermine a mother's ability to exclusively breastfeed.

Interventions aimed at promoting breastfeeding must therefore address broader socio-

economic barriers, including poverty alleviation, labor rights advocacy for breastfeeding

mothers, and social protection measures that enable women to breastfeed optimally.

Healthcare System and Policy Support

The role of healthcare systems and public policies in shaping breastfeeding practices

cannot be overstated. Health facilities that adhere to the WHO/UNICEF Baby-Friendly

Hospital Initiative (BFHI) ten steps to successful breastfeeding have been shown to

significantly improve breastfeeding initiation and duration rates (WHO, 2023). Early skin-

to-skin contact, rooming-in practices, and breastfeeding counseling are critical components

of successful breastfeeding support within healthcare settings.

In Nigeria, however, the implementation of BFHI policies is inconsistent, and many

mothers do not receive adequate breastfeeding support during the critical postpartum

period (NPC & ICF, 2023). Health worker training, supportive hospital policies, and

community health outreach programs are essential strategies to enhance breastfeeding

support systems. Legislative measures such as the International Code of Marketing of

Breast-milk Substitutes, which seeks to regulate the promotion of infant formula, are

crucial in protecting breastfeeding from commercial pressures. Enforcement of maternity

leave policies, public breastfeeding rights, and workplace accommodations for

breastfeeding mothers are additional policy interventions that can create enabling

environments for breastfeeding.

Psychosocial and Emotional Factors

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Maternal confidence, self-efficacy, and emotional well-being are vital to breastfeeding

success. Mothers who perceive themselves as capable of breastfeeding and who receive

positive reinforcement from family, peers, and healthcare providers are more likely to

initiate and sustain breastfeeding (Kim et al., 2020). Conversely, maternal anxiety,

postpartum depression, and perceived insufficient milk supply are common barriers to

breastfeeding.

Peer support programs, mother-to-mother support groups, and counseling services can

enhance maternal confidence and resilience in the face of breastfeeding challenges.

Emotional support from partners and family members also plays a critical role. Studies

have shown that women who receive partner support are significantly more likely to

initiate and continue breastfeeding compared to those who do not (Sharma & Byrne,

2023). Thus, interventions must address not only informational needs but also the

emotional and psychosocial dimensions of breastfeeding to achieve sustainable

improvements in breastfeeding outcomes.

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Theoretical Review

In studies focusing on health behaviors such as breastfeeding, the application of

established theories allows researchers to uncover the complex interplay of cognitive,

emotional, social, and structural factors influencing individuals’ decisions. For this study

assessing the knowledge and practices related to breastfeeding patterns among nursing

mothers in Rumuigbo, Rivers State, two relevant theories are employed: the Health Belief

Model (HBM) and the Theory of Planned Behavior (TPB). These models are particularly

suitable as they offer insights into the motivational and perceptual dimensions that shape

maternal health behaviors.

Health Belief Model (HBM)

The Health Belief Model (HBM) is among the earliest and most influential theoretical

models in health psychology, developed initially by social psychologists Godfrey

Hochbaum, Irwin Rosenstock, and Stephen Kegels in the 1950s under the U.S. Public

Health Service (Rosenstock, 1974). The model was created to explain why individuals

failed to participate in preventive health programs, such as tuberculosis screening, despite

the availability of free and accessible services. Over time, the HBM has been extensively

adapted to predict a wide range of health-related behaviors, including vaccination uptake,

medication adherence, safe sexual practices, and maternal-child health interventions such

as breastfeeding.

The core premise of the HBM is that individuals are likely to engage in a health-related

behavior if they perceive themselves to be susceptible to a health problem (perceived

susceptibility), believe the problem would have serious consequences (perceived severity),

believe that taking a particular action would reduce their susceptibility or mitigate the

19
severity (perceived benefits), and believe that the benefits of taking action outweigh the

costs or barriers involved (perceived barriers). Later extensions of the model incorporated

two additional constructs: cues to action and self-efficacy (Champion & Skinner, 2008).

Perceived Susceptibility: This refers to an individual's assessment of their risk of

developing a health condition. If people believe they are at high risk, they are more

likely to engage in behaviors to reduce that risk.

Perceived Severity: This involves beliefs about the seriousness of a condition and its

potential consequences. Perceptions of both medical and social consequences are included.

Perceived Benefits: This construct assesses the perceived effectiveness of the

recommended health behavior in reducing the risk or severity of the health condition.

Perceived Barriers: These are the potential negative aspects of a health action that may

act as impediments to undertaking the recommended behavior. Barriers can include

physical, psychological, social, and economic costs.

Cues to Action: These are triggers that prompt individuals to adopt a behavior, such as

advice from others, illness of a family member, or media campaigns.

Self-Efficacy: Introduced in later versions of the HBM, self-efficacy refers to an

individual's confidence in their ability to successfully perform the recommended behavior

(Bandura, 1977).

The HBM has been widely validated across multiple studies and has demonstrated

significant explanatory power for health-related behaviors. However, critics of the HBM

point out that it tends to focus heavily on individual cognition, often underemphasizing

broader social, economic, and environmental influences on health behavior (Glanz, Rimer,

& Viswanath, 2015). Moreover, the HBM presumes that individuals behave rationally and

20
systematically evaluate the risks and benefits of action, which may not always be the

case in real-world settings.

Despite these limitations, the HBM remains a robust framework, particularly useful for

designing and implementing interventions aimed at changing health behaviors through

modifying beliefs and perceptions.

Application of the Health Belief Model to the Study

In the context of this study, which seeks to assess knowledge and practices related to

breastfeeding patterns among nursing mothers in Rumuigbo, Rivers State, the Health

Belief Model offers valuable insights. Breastfeeding is a health behavior influenced by

mothers' beliefs regarding the susceptibility of their infants to illnesses, the severity of

potential health problems, and the perceived benefits of breastfeeding in promoting infant

health and development.

Perceived susceptibility plays a crucial role. Mothers who recognize that their infants are

vulnerable to infections and malnutrition without exclusive breastfeeding are more likely

to practice exclusive breastfeeding. Conversely, a low perception of susceptibility may

lead to early weaning or supplementation with formula or traditional remedies.

Perceived severity is another key factor. If mothers believe that failure to breastfeed

exclusively can lead to severe health issues, such as diarrhea, respiratory infections, or

stunted growth, they are more motivated to adhere to recommended breastfeeding

practices.

Perceived benefits are central to motivating positive breastfeeding behaviors. Mothers who

understand that breastfeeding strengthens the infant’s immune system, fosters cognitive

21
development, and promotes bonding are more inclined to continue breastfeeding despite

challenges.

Perceived barriers in Rumuigbo include cultural beliefs, lack of workplace support, breast

pain, or misconceptions about breastmilk insufficiency. Identifying and addressing these

barriers is crucial for improving breastfeeding practices.

Cues to action, such as breastfeeding education during antenatal clinics, advice from

healthcare workers, and peer support groups, serve as important triggers encouraging

mothers to initiate and sustain breastfeeding.

Self-efficacy is vital for ensuring the continuation of breastfeeding. Mothers who feel

confident in their ability to produce sufficient milk and to manage breastfeeding

difficulties are more likely to exclusively breastfeed for six months as recommended by

the World Health Organization (WHO, 2023).

Therefore, by utilizing the HBM, this study can better understand the cognitive and

perceptual processes that facilitate or hinder optimal breastfeeding practices among

mothers in Rumuigbo.

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Empirical Review

This section presents a comprehensive review of an empirical study closely related to the

present research topic, focusing on the patterns of breastfeeding, knowledge, and practices

among nursing mothers.

The empirical study reviewed is that of Ogbo, F. A., Agho, K. E., Page, A., & Ezeh,

O. K. (2021) titled "Determinants of suboptimal breastfeeding practices in Nigeria:

Evidence from the 2018 Nigeria Demographic and Health Survey." Published in the

journal BMC Public Health, this research provides a robust analysis of breastfeeding

practices among Nigerian women and offers critical insights applicable to nursing mothers

in Rumuigbo, Rivers [Link] study utilized secondary data from the 2018 Nigeria

Demographic and Health Survey (NDHS), which remains the most recent and

comprehensive national dataset on maternal and child health indicators in Nigeria. Using

a large, representative sample of over 30,000 women aged 15 to 49 years, the study

examined breastfeeding initiation, exclusivity, and continuation, identifying socio-

demographic, cultural, and healthcare-related determinants of breastfeeding behaviors.

Ogbo et al. (2021) adopted a cross-sectional design, employing quantitative data analysis

techniques. Data were collected through structured interviews conducted nationwide under

the NDHS framework. Variables included maternal age, education, household wealth

index, region of residence, employment status, mode of delivery, and exposure to

antenatal and postnatal care.

Multivariable logistic regression analyses were conducted to identify associations between

these predictors and breastfeeding practices, adjusting for potential confounders. The large

sample size and rigorous statistical techniques ensured that the study’s findings were

23
robust, generalizable, and reflective of breastfeeding realities in Nigeria. The use of

nationally representative data allowed for a comprehensive understanding of patterns at

both regional and national levels, providing an important evidence base for public health

interventions targeting improved breastfeeding outcomes.

The study revealed several critical findings:

Early Initiation: Only 42% of newborns were breastfed within the first hour of birth,

despite the WHO recommendation emphasizing early initiation.

Exclusive Breastfeeding: Approximately 29% of infants under six months were

exclusively breastfed. This figure remains significantly below Nigeria’s national target and

global recommendations.

Continued Breastfeeding: While breastfeeding continued into the second year for many

infants, the rates sharply declined after six months as supplementary feeding practices

were widely introduced.

Ogbo et al. (2021) also went further to identify multiple factors that could influence

breastfeeding behaviors:

Maternal Education: Mothers with secondary or higher education were more likely to

initiate breastfeeding early and practice exclusive breastfeeding compared to those with

no formal education. Education enhanced awareness about the benefits of breastfeeding

and reduced the likelihood of harmful traditional practices.

Health Facility Delivery: Women who delivered in health facilities were almost twice as

likely to initiate breastfeeding early compared to those who delivered at home. Health

workers’ advice during delivery appeared critical in influencing immediate breastfeeding

behaviors.

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Antenatal and Postnatal Care Visits: Receiving breastfeeding counseling during

antenatal care significantly increased the likelihood of exclusive breastfeeding. Similarly,

postnatal visits that included breastfeeding advice improved breastfeeding practices.

Household Wealth: Paradoxically, higher household wealth was associated with a lower

likelihood of exclusive breastfeeding. The authors suggested that wealthier mothers may

have greater access to breastmilk substitutes, perceive formula feeding as more modern,

or return to work earlier.

Employment Status: Maternal employment, particularly among mothers without maternity

protections or supportive workplace policies, significantly reduced the likelihood of

exclusive breastfeeding. Many employed mothers introduced mixed feeding early due to

work demands.

Regional Differences: Marked variations were observed between geopolitical zones, with

southern regions exhibiting relatively better breastfeeding indicators than northern zones.

Nevertheless, urban-rural disparities persisted, with urban mothers less likely to

exclusively breastfeed.

Barriers to Optimal Breastfeeding

The study illuminated major barriers undermining optimal breastfeeding practices:

Cultural Beliefs and Traditions: Prelacteal feeding practices, deeply rooted in cultural

beliefs, continued to be widespread. Water, herbal teas, and honey were commonly given

to newborns within the first few days of life, delaying breastfeeding initiation.

Perceptions of Insufficient Milk: A prevalent belief that breastmilk alone is insufficient,

especially in hot climates, led many mothers to introduce water and other liquids early.

25
Aggressive Marketing of Formula: In urban areas particularly, aggressive promotion of

breastmilk substitutes eroded breastfeeding norms and practices.

Lack of Breastfeeding Support Services: Absence of lactation consultants, inadequate

breastfeeding counseling during healthcare visits, and unsupportive hospital policies (such

as separation of mother and child post-delivery) were systemic challenges.

Relevance of the Study to the Current Research

The study by Ogbo et al. (2021) holds significant relevance to the present investigation

of breastfeeding patterns among nursing mothers in Rumuigbo, Rivers State:

1. Contextual Similarity: Nigeria’s diverse socio-economic and cultural landscape mirrors

the situation in Rumuigbo. The findings about low exclusive breastfeeding rates and early

supplementation reflect patterns suspected in the local community.

2. Identification of Key Predictors: By highlighting maternal education, healthcare

service utilization, cultural practices, and employment status as key predictors, the study

provides a framework for analyzing the breastfeeding patterns in Rumuigbo.

3. Focus on Knowledge-Practice Gap: The demonstrated gap between breastfeeding

knowledge and practice offers critical insights for the current study, which also seeks to

understand why nursing mothers, despite possessing knowledge about breastfeeding, may

not adhere to recommended practices.

4. Policy Implications: The emphasis on healthcare-based interventions, workplace

accommodations for breastfeeding mothers, and culturally sensitive education campaigns

aligns with the present study’s goals of recommending feasible strategies for improving

breastfeeding practices among mothers in Rumuigbo.

26
While Ogbo et al.’s study presents strong, large-scale evidence, certain limitations must

be noted:

Cross-sectional Design: The study's cross-sectional nature prevents establishing causal

relationships. Longitudinal studies would provide stronger evidence of how various factors

dynamically influence breastfeeding behaviors over time.

Self-reported Data: Breastfeeding practices were based on mothers’ self-reports, which

may be subject to recall bias or social desirability bias.

Limited Local Context: Although representative nationally, regional nuances, particularly

local beliefs specific to smaller communities like Rumuigbo, may not be fully captured.

Nonetheless, the study’s methodological rigor, comprehensive analysis, and policy

relevance make it a valuable empirical foundation for studies assessing breastfeeding

knowledge and practices in local Nigerian contexts.

Conclusion

The empirical evidence provided by Ogbo et al. (2021) significantly enhances the

understanding of breastfeeding behaviors among Nigerian mothers. The insights into

socio-demographic, healthcare, and cultural determinants inform the analysis of

breastfeeding patterns in Rumuigbo. Importantly, the study underscores the multifaceted

nature of breastfeeding behaviors and the need for context-specific, culturally sensitive,

and systemic interventions to bridge the gap between breastfeeding knowledge and

practice.

Breastfeeding Patterns: The specific ways in which mothers breastfeed, including initiation

timing, exclusivity, frequency, and duration.

27
Socio-cultural Factors: Beliefs, customs, values, and social norms that influence individual

behaviors and decisions related to breastfeeding.

28
 CHAPTER THREE

RESEARCH METHODOLOGY

Research Design

This study employed a descriptive cross-sectional survey design to assess the knowledge

and practices related to breastfeeding patterns among nursing mothers in Rumuigbo,

Rivers State. A cross-sectional design was deemed appropriate because it enables the

researcher to capture data from a defined population at a single point in time, thus

allowing the investigation of current knowledge levels, attitudes, and behaviors without

manipulating variables (Polit & Beck, 2021). The descriptive approach is essential when

the goal is to systematically describe existing phenomena rather than to investigate causal

relationships or [Link], this design facilitates the identification of

patterns and relationships between sociodemographic characteristics and breastfeeding

behaviors, providing a foundation for developing targeted health education and

intervention strategies. By adopting a non-experimental, observational approach, the study

preserves the naturalistic conditions under which nursing mothers in Rumuigbo engage in

breastfeeding practices.

Research Setting

The study was conducted in Rumuigbo, a semi-urban community located in Obio/Akpor

Local Government Area of Rivers State, Nigeria. Rumuigbo is notable for its growing

population and mixed socio-economic characteristics, with residents engaging in various

occupations such as petty trading, civil service, artisan work, and small-scale businesses.

29
The community is home to a variety of healthcare facilities, including primary health

centers, private maternity clinics, and traditional birth homes, which provide services

relevant to maternal and child health, including breastfeeding education and postnatal

care.

Rumuigbo is culturally diverse, inhabited by people from different ethnic backgrounds,

though predominantly Ikwerre. The area exhibits a blend of traditional and modern

practices, especially in maternal and child health behaviors. This makes it a suitable

setting for examining knowledge and practices related to breastfeeding among nursing

mothers. Accessibility to healthcare facilities and exposure to health promotion messages

vary among residents, potentially influencing breastfeeding patterns and maternal

knowledge levels.

Given its demographic diversity and health service availability, Rumuigbo offers a

representative setting for assessing the level of awareness, understanding, and practical

application of breastfeeding practices among nursing mothers. The findings from this

location may provide insights applicable to similar peri-urban communities across Rivers

State and Nigeria at large.

Population of the Study

The population of the study comprised all nursing mothers residing within the

geographical bounds of Rumuigbo community in Obio/Akpor Local Government Area of

Rivers State. For the purpose of this research, a nursing mother was operationally

defined as any woman actively breastfeeding a child aged 0 to 24 months, regardless of

whether breastfeeding was exclusive, mixed, or complementary.

30
Based on recent records obtained from local primary health centers, child welfare clinics,

and community health workers, the estimated number of nursing mothers in Rumuigbo

was approximately 950. This population size was considered sufficiently large to allow

for robust statistical analysis, yet manageable in terms of sampling logistics.

The demographic diversity of Rumuigbo — which includes mothers of varying

socioeconomic backgrounds, educational levels, cultural affiliations, and religious beliefs

— enhances the relevance of the study findings for broader public health planning.

Sample Size

The sample size was calculated using Taro Yamane’s (1967) formula for finite

populations:

n = \frac{N}{1 + N(e)^2}

Where:

= required sample size

= population size (950)

= level of precision (0.05)

Substituting into the formula:

n = 950/{1 + 950(0.05)^2}

n = 950/{1 + 950(0.0025)} ]

n = 950/{1 + 2.375}

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n = 950/{3.375} ]

n = 281

To account for non-responses or incomplete questionnaires, the sample size was rounded

up to 300 nursing mothers.

Sampling Technique

A multistage sampling technique was employed:

Stage 1: Purposive Sampling — Rumuigbo community was purposively selected based on

the presence of accessible healthcare facilities and the diversity of its population.

Stage 2: Cluster Sampling — The community was divided into identifiable clusters based

on geographical segmentation (streets and compounds).

Stage 3: Proportionate Stratified Sampling — Nursing mothers within each cluster were

stratified proportionally to their estimated numbers.

Stage 4: Simple Random Sampling — Using a lottery method, participants were

randomly selected within each stratum to minimize sampling bias and to ensure that

every nursing mother had an equal probability of inclusion.

This rigorous sampling approach enhanced the representativeness and generalizability of

the findings to the entire population of nursing mothers in the community.

32
Instrumentation

The research instrument used for this study was a structured questionnaire designed by

the researcher to collect relevant data aligned with the research objectives and questions.

The questionnaire was divided into four major sections, as follows:

Section A: Demographic Information

This section captured background data of the respondents, including age, marital status,

educational level, number of children, and occupation.

Section B: Knowledge and Awareness of Family Planning Methods

This section addressed Research Question 1, using 10 items designed to assess the

respondents’ understanding of family planning, available methods, access points, and

general awareness. Responses were rated using a 5-point Likert scale ranging from

“Strongly Agree” to “Strongly Disagree.”

Section C related to Research Question 2 and contained 10 items designed to evaluate

the respondents’ perceptions, beliefs, and personal views on the acceptability, benefits,

and possible misconceptions about family planning. A 5-point Likert scale was also used.

Section D: Factors Influencing the Use or Non-Use of Family Planning

This section addressed Research Question 3, with 10 items aimed at identifying the

major barriers or motivators affecting the use of family planning services. The Likert

scale format helped to measure the degree of influence of these factors.

33
Validity Of Instrument

Content validity was established through a review by three subject-matter experts — two

public health specialists and a maternal-child health nurse educator. They evaluated the

questionnaire for relevance, coverage of the study objectives, clarity, and cultural

appropriateness. Their feedback led to the rewording of ambiguous items, removal of

redundant questions, and incorporation of culturally relevant examples.

Additionally, face validity was ascertained during the pilot testing phase, where feedback

from participants confirmed that the questionnaire was easily understandable and

appropriately captured the intended constructs.

Reliability Of Instrument

To establish the reliability of the research instrument, the test-retest method was

employed. This involved administering the same questionnaire to a group of 10 nursing

mothers who were not part of the main study sample but shared similar characteristics

with the target population. The instrument was administered twice to the same

respondents within an interval of two weeks to minimize memory effect and ensure

stability over time.

The scores obtained from the first and second administrations were analyzed using the

Pearson Product-Moment Correlation Coefficient (r) to determine the consistency of

responses over time. A reliability coefficient of 0.84 was obtained, indicating a high

level of reliability of the instrument. According to statistical conventions, a reliability

coefficient above 0.70 is generally considered acceptable (Creswell & Creswell, 2018).

34
This result confirms that the instrument was stable and dependable for collecting accurate

and consistent data from the study respondents.

Method of Data Collection

Data collection spanned five weeks to allow sufficient time for reaching the targeted

sample size, considering the busy schedules of nursing mothers.

The Self-Structured Questionnaire provided data that is objective and reliable for testing.

The researcher ensured that the data collection process is properly administered. Research

assistants were also carefully selected and trained on how to administer the

questionnaires to the respondents. The data collection instrument was also carefully

administered, discussed and explained to the respondents for ease of understanding.

Respondents took approximately 20–30 minutes to complete the questionnaire. To

maximize response rates, light refreshments and infant care items (e.g., wipes, soap) were

given as appreciation tokens.

Method of Data Analysis

Data were coded and entered into SPSS version 26.0 for analysis. Descriptive statistics

were used to present demographic characteristics and responses:

Frequencies and percentages for categorical variables.

Means and standard deviations for continuous variables.

Inferential statistical tests were employed to test hypotheses and explore relationships:

35
Chi-square tests (χ²) were used to assess associations between categorical variables (e.g.,

education level and exclusive breastfeeding practice).

Independent t-tests and One-way ANOVA were used where appropriate to compare

means between groups.

Logistic regression was applied to identify predictors of good breastfeeding practices.

All statistical tests were conducted at a 95% confidence interval, with p < 0.05

considered statistically significant. Results were presented in accordance with APA 7th

edition formatting guidelines, with clear tables, charts, and narrative explanations.

Ethical Considerations

Ethical clearance was obtained from the Rivers State Ministry of Health Ethical Review

Board. Additional permission was sought from the local community authorities and health

facility managers.

Participation was voluntary, and a written informed consent form was provided, detailing

the purpose of the study, procedures involved, potential risks, and benefits. Respondents

were informed of their right to withdraw at any stage without any repercussions.

Confidentiality and anonymity were strictly upheld:

Names or personal identifiers were not collected.

Data were stored securely and accessed only by the researcher.

36
Results were presented in aggregate form to avoid identification of individual participants.

Furthermore, cultural sensitivity was maintained throughout the study, and extra efforts

were made to ensure that all interactions respected the dignity and autonomy of the

nursing mothers.

37
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