Practice of Breastfeeding among Mothers Attending

Immunization Clinics in Primary Health Care Centres,

Southwest-Nigeria: A Cross-sectional Study
Solomon Olusoji Abidemi, Akinwumi Adebowale Femi, Solomon
Oluremi Olayinka, Ajayi Paul Oladapo, Deji Samson Ayo, Oluyide
Olumuyiwa Peter, and Popoola Tomilayo Ajoke
European Journal of Health Sciences
ISSN 2520-4645 (online)
Vol.8, Issue 2, pp 20 - 31, 2023 [Link]

Practice of Breastfeeding among Mothers Attending Immunization Clinics in

Primary Health Care Centres, Southwest-Nigeria: A Cross-sectional Study

Solomon Olusoji Abidemi1, Akinwumi Abstract

Adebowale Femi2, Solomon Oluremi Purpose: Breastfeeding has been endorsed by the
Olayinka2, Ajayi Paul Oladapo2, Deji
World Health Organization as the most effective
Samson Ayo2, Oluyide Olumuyiwa method to feed infants. To find out the
Peter3, and Popoola Tomilayo Ajoke4 breastfeeding practices and examine the factors
1
Family Medicine Department, College affecting the practice among mothers attending
of Medicine, Ekiti State University, immunization clinics at Primary Health Centers
Ado-Ekiti, Nigeria within Ado-Ekiti in Nigeria.
2
Community Medicine Department, Methodology: A total of 450 respondents were
College of Medicine, Ekiti State randomly selected with Fisher’s formula using a
University, Ado-Ekiti, Nigeria cross-sectional descriptive study design.
3 Multistage sampling techniques was used to select
Community Medicine Department,
two out of fifteen wards in Ado Local
Uniosun Teaching Hospital, Osogbo,
Government Area through random sampling by
Nigeria
balloting, out of which two Primary Health Care
4
Community Medicine Department, was selected one from each Local Government
Ekiti State University Teaching Area. Adapted, semi-structured, interview
Hospital, Ado-Ekiti, Nigeria administered questionnaire was used, data was
Corresponding Author’s Email: entered and analyzed with Statistical Package for
abide7000@[Link] Social Sciences version 25 and p value set at 5%.

Article History Findings: Out of the respondents, 152 (33.8%)

exclusively breastfed their babies and 163
Received: 21st Feb 2023 (36.2%) initiated breastfeeding within one hour
Received in revised form: 8th Mar 2023 after delivery. One hundred and thirty-two
Accepted on: 16th Mar 2023 (29.3%) gave pre-lacteal feeding to their babies,
of whom 93 (70.4%) gave water and glucose.
From the multivariate analysis, the mothers that
were employed were more likely to exclusively
breastfed their babies with OR of 1.58 and p value
of <0.05. The primiparous mothers were less
likely to initiate breastfeeding within one hour of
delivery OR of 0.62 and p value of 0.03.
Recommendation: Significant numbers of the
mothers were still not practicing exclusive
breastfeeding and not initiating breastfeeding
early enough after delivery. There is need to
educate women especially the primiparous
mothers on the benefits of early initiation of
breastfeeding and danger of pre-lacteal feeding.
Keywords: Breastfeeding, mothers, practice,
primary care, Nigeria

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INTRODUCTION
Adequate nutrition during infancy and early childhood is of great importance to children for
their growth, health, and development to maximum potential. It has been acknowledged
globally that breastfeeding has both maternal and child benefits, because breast milk has been
found to contain all the required nutrients for infant growtht.1 Exclusive breastfeeding (EBF)
has been endorsed by the World Health Organization (WHO) as the most effective method to
feed infants. It is the intake of breast milk only, without water, tea, herbal preparations, or food-
by an infant for the first six months of life except for intake of drops or syrups consisting of
vitamins, mineral, supplements, or medicine that has been prescribed. 2-4
Breast milk is a natural and renewable source of essential fats, carbohydrates, protein, vitamins
and minerals, enzymes, hormones, growth factors, anti-inflammatory agents and
immunological factors that fulfills all the nutritional requirement of an infant during the first 6
months of life,4,5 and is therefore ideal for the proper development of an infant. Due to the rich
constitution of the breast milk, the WHO and UNICEF have recommended the following on
breastfeeding: commencement of breastfeeding within the first hour of life, EBF for the first
six months of life and continued breastfeeding for two years or more together with suitable
complementary feeding starting from the sixth month of life2 -this is the stage in which breast
milk alone is not sufficient to give the required energy and nutrients to sustain normal growth
and optimal health and development.
There are numerous merits of EBF, for the child, there is improved neurological development
and protection against diarrhea, common childhood respiratory tract illness such as pneumonia,
otitis media, and malnutrition. It may also have long-term benefits, like reduction in the risk of
overweight and obesity in childhood and adolescence.1 As such, it has been regarded as a public
health intervention and one of the most effective method to reduce infant morbidity and
mortality rates.6,7 For the mother, reduced risk of breast cancer, ovarian cancer, type 2 diabetes,
metabolic syndrome, and quick return to pre-pregnancy weight are important benefits.6
Furthermore, it facilitates bonding between mother and child and helps to improve natural birth
spacing. Increased household income and improved food security are also advantages
associated with EBF.6
Although the benefits of breastfeeding are enormous, some factors have been identified to
hinder its practice among which are inadequate lactation, work-related problems, and medical
problems of either the mother or infant.5 There are also multiple factors influencing the practice
of breastfeeding including social, cultural, health, psychosocial and economic factors.2,4 Some
of the factors influencing the initiation and continuation of breastfeeding identified in several
studies are maternal age, education, ante-natal care attendance, mode of delivery, place of
delivery, parity, employment status, pressure from family and cultural values.2,4,6 Furthermore,
it has been shown in other studies that many mothers find it strenuous to meet personal goals
and to stick to recommended guidelines for exclusive and continued breastfeeding despite the
high initiation rate. For example Oche et al in Sokoto, in the northern Nigeria documented 53%
prevalence of early initiation of breastfeeding and 31% prevalence of exclusive breastfeeding.6
Other causes include breast problems like sore nipples or mother’s perception of not
sufficiently lactating and limited breastfeeding knowledge.1 These factors however vary in
different settings and among women of same ethnicity.4
Despite the campaign and increased awareness of the effectiveness of EBF by various
governmental and non-governmental bodies, in SSA, the pooled prevalence of early initiation
of breastfeeding after delivery was 58.3%, though there are differences across different
countries. These differences range from 24% in Chad to 86% in Burundi. 7 Only 39% of infants

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in developing countries were exclusively breastfed.4 In keeping with this, the Nigerian
Demographic Health Survey in 2018 reported that less than one-third (29%) of infants in the
first six months of life were EBF and this proportion was found to reduce with increasing age.
The figures dropped from 39% to 29% among infants aged 0-1month and 2-3months with a
further decline to 18% among infants aged 4-5 months. 8 Prevalence of early initiation of
breastfeeding for newborn in Nigeria ranges from 36.6% to 53% while exclusive breastfeeding
ranges from 31% to 58.8%. 2, 6, 9
Breastfeeding practices, especially in developing countries including Nigeria, continue to be
suboptimal despite the huge maternal and child benefits. In view of this, comprehending the
breastfeeding practices and its predictors is imperative to designing appropriate and effective
interventions that will positively impact the practice. The aim of this study was to find out the
breastfeeding practices and examine the sociodemographic factors affecting breastfeeding
practices among mothers attending immunization clinics in Ado-Ekiti in Nigeria.
METHODS
The study was a descriptive cross-sectional study carried out between June 2020 and September
2020 in immunization clinics of two primary health centers in Ado Local Government of Ekiti
State. Mother and the child pair were the target population.
Study Setting
Ado LGA is the capital of Ekiti State. It has 13 wards and there is at least one comprehensive
or basic health center and one health post in each ward in the Local Government. Immunization
clinic takes place in all the primary health centers at least once in a week. Two of the thirteen
wards in the LGA were selected through simple random sampling by balloting. The selected
wards have comprehensive health centers which were chosen for the study. Average of fifty
clients were seen during the immunization clinics in each of the two selected health centers. A
multistage sampling technique was used in selecting 450 mother/child pairs as follows;
participants were chosen by systematic random sampling with sample interval of three, the first
client was balloted for using simple random sampling. If anyone refuse to participate,
automatically the next patient was chosen from the register. The participants were mothers from
age 18 to 45 years with children age 0 – 24 months who were still breastfeeding. Mothers who
were sick or nursing a sick child were excluded from the study
Sample Size Determination
Sample size was calculated to be 410 with the formula for cross-sectional descriptive studies
using the Fishers formula 10 at a prevalence of 38.8% obtained from a previous study, 6
confidence interval of 95%, margin of error of 0.05 with non-response rate of 10%.
Data Collection
A structured, interviewer administered questionnaire was used. Questionnaire was pre-tested
in another health center of a ward different from the selected ones and ambiguous questions
were reframed for clarity. The questionnaire had three sections: the first section was on socio-
demographic characteristics (age, educational level, tribe, occupation etc.), second section on
pre and post-natal history (parity, mode of delivery, where delivery took place, was the
pregnancy planned). The third section was on the practice of breastfeeding (when breastfeeding
was initiated, pre lacteal feeding, is baby breastfed exclusively?) Four Resident Doctors were
trained in data collection as research assistants.
Outcome/Dependent variable was the breastfeeding practice. This was assessed by early

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initiation of breastfeeding after delivery that is initiating breastfeeding within the first one hour
after delivery. Also, by exclusive breastfeeding which is giving the baby only breast milk for 6
months without water and drugs except prescribed. Independents variables were the age of the
mothers, age of the babies, educational level of the mothers, occupation of the mothers etc.
Data Analysis
Data was entered and analyzed with Statistical Package for Social Sciences (SPSS) version 25.
Summary statistics was presented using tables. Age was categorized and summarized with
mean and standard deviation. Parity was summarized with median and interquartile range.
Categorical variables were presented as proportions. Binary logistic regression analysis was
done for variables that were significantly associated at the bivariate level of analysis; odd ratios
(OR) at 95% confident interval was reported. The significant level of 5% was set for all
statistical procedures. Ethical clearance for the study was obtained from the Ethics and
Research Review Committee of the Ekiti State University Teaching Hospital, Ado-Ekiti with
protocol number EKSUTH/A62/2020/09/012
RESULTS
In table 1, the majority 438 (97.3%) of the respondents were married, 398 (88.4%) were
Christians, 398 (88.4%) employed and 386 (85.8%) were Yoruba. The table shows that 354
(78.7%) of the respondents planned the pregnancy, 340 (75.6%) had someone to help at home
apart from their spouse after discharge from postpartum ward. Majority 399 (88.7%) had
prenatal education on EBF and 157 (34.9%) of them were primiparous. Almost half of the
respondents 204 (45.3%) delivered in the government hospitals while 148 (32.9%) delivered
in Mission Homes.
Figure 1 revealed that 163 (36.2%) of the mothers, initiated breastfeeding of their newborn
early, that is within the first one hour after delivery and 167 (37.1%) initiated breastfeeding 3
hours after delivery. Figure 2 shows the prevalence of exclusive breastfeeding in this study was
152 (33.8%). Almost a third (29.3%) of the respondents gave pre-lacteal feeding of which 93
(70.3%) gave water and glucose, while 185 (41.1%) fed their babies with artificial milk before
6 months of age. One hundred and twenty-three (27.3%) bottled fed their babies before 6
months as shown in table 2.
Table 1: Socio-demographic and Obstetric characteristics of the respondents

Variable Frequency n=450 Percentage

Sex of Infant
Male 228 50.7
Female 222 49.3
Maternal Age
≤ 30 years 233 51.8
≥ 30 years 217 48.2
Mean age 29.48±5.17 years
Ethnicity
Yoruba 386 85.8
Others 64 14.2

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Education
≤ Secondary 210 46.7
≥ Tertiary 240 53.3
Employment
Employed 398 88.4
Unemployed 52 11.6
Religion
Christianity 398 88.4
Islam 52 11.6
Marital Status
Married 438 97.3
Single 12 2.7
Parity
Primiparous 157 34.9
Multiparous 293 65.1
Median 2 Range (1 – 9)
Interquartile 1 – 25, 2 – 50, 3 – 75
Planned Pregnancy
Yes 354 78.7
No 96 21.3
Prenatal Education on EBF
Yes 399 88.7
No 51 11.3
Place of Delivery
Government Hospital 204 45.3
Mission 148 32.9
Private Hospital 81 18
Home 17 3.8
Mode of Delivery
SVD 411 91.3
C/S 39 8.7
Helping hand
Yes 340 75.6
No 110 24.4

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Figure 1: Time of initiating breastfeeding

Figure 2: Exclusive breastfeeding practice

Table 2: Practice of breastfeeding among respondents

Variables Frequency (n = 450) Percentage

Pre-lacteal feeding
NO 318 70.7
YES 132 29.3
- Water 19 14.4
- Water & glucose 93 70.4
- Artificial milk 20 15.2
Give cereal before 6 m
Yes 179 39.8
No 271 60.2

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Herbal concoction before 6 m

Yes 214 47.6
No 236 52.4
Artificial milk before 6 m
Yes 185 41.1
No 265 58.9
Bottle feeding before 6 m
Yes 123 27.3
No 327 72.7
Exclusive Breastfeeding
Yes 152 (33.8)
No 298 (66.2)
Is BF at work convenient
Yes 406 90.2
No 44 9.8
Note: BF is breastfeeding
Bivariate analysis was conducted between sociodemographic characteristics and practice of
exclusive breastfeeding using chi square. Bivariate analysis also was conducted between
sociodemographic characteristics and early initiation of breastfeeding with chi square. The
variables that were statistically significant with p values < 0.05 were used in conducting the
multivariate analysis. The results of the multivariate analysis are as shown in Tables 3 & 4.
Table 3 revealed that the mothers age above 30 years were more likely to practice exclusive
breastfeeding compared to their counterpart 30 years and less with OR of 1.58 and p value <
0.05. mothers of other religion apart from Christianity were more than two times more likely
to practice exclusive breastfeeding compared to the Christian mothers with p value of 0.005.
Table 4 revealed that the mothers that were employed and those not having anyone assisting
them immediately after delivery apart from their spouse were more likely to initiate
breastfeeding within one hour after delivery with OR of 2.29 and 1.70 respectively and p values
of 0.023 and 0.024 respectively.
Table 3: Logistic regression of predictors in the practice of exclusive breastfeeding
among the respondents

Variables Practice of EBF B OR (95% CI) p-value

Yes No
Mothers’ Age
≤ 30 64 (27.5) 169 (72.5) 1
> 30 88 (40.6) 129 (59.4) 1.582 1.005 – 2.488 0.047*
Educational level
≤ Secondary * 62 (29.5) 148 (70.5) 1
≥Tertiary 90 (37.5) 150 (62.5) 1.396 0.921 – 2.115 0.116

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Religion
Christianity 126 (31.7) 272 (68.3) 1
Others 26 (50.0) 26 (50.0) 2.346 1.292 – 4.257 0.005*
Parity
Multiparous 108 (36.9) 185 (63.1) 1
Primip 44 (28.0) 113 (72.0) 0.813 0.505 – 1.310 0.395
*Significant p value
Table 4: Logistic regression of predictors in the early initiation of breastfeeding among
the respondents

Variables Early Initiation of BF AOR CI (95% CI) p-value

Yes No
Employment
Unemployed 152 (38.2) 246 (61.8) 1
Employed 11 (21.2) 41 (78.8) 2.290 1.023 – 4.681 0.023*
Parity
Multiparous 120 (41.0) 173 (59.0) 1
Primip 43 (27.4) 114 (72.6) 0.621 0.400 – 0.965 0.034*
Helping hand
Yes 112 (32.9) 228 (67.1) 1
No 51 (46.4) 59 (53.6) 1.695 1.073 – 2.677 0.024*
Mode of delivery
SVD 156 (38.0) 255 (62.0) 1
C/S 7 (17.9) 32 (82.1) 0.407 0.170 – 0.974 0.043*
Place of delivery
Home 6 (35.3) 11 (64.7) 1
Government H 86 (42.2) 118 (57.8) 0.729 0.231 – 2.303 0.590
Mission H 51 (34.5) 97 (65.5) 0.591 0.323 – 1.082 0.890
Private H 20 (24.7) 61 (75.3) 0.954 0.498 – 1.827 0.888
*Significant p value, BF is breastfeeding
DISCUSSION
It has been recommended by WHO that children should be breastfeed continuously for two
years and for the first six mouth of life, breastfeeding should be exclusive. To optimize the
advantage, initiation of breastfeeding should be within the first one hour after delivery.1, 2 This
study was designed to examine the practice of breastfeeding among mothers attending
immunization clinics in Ado Ekiti.

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The prevalence of exclusive breastfeeding in this study was 33.8% while that of early initiation
of breastfeeding was 36.2%. The prevalence of exclusive breastfeeding in this study is
comparable to the study in Indonesia,3 the prevalence from the Sub Saharan African countries,4
Gambia,5 Edo State, Nigeria2 and Sokoto, Nigeria.6 However, the prevalence of exclusive
breastfeeding gotten from this study was higher than the national prevalence of 29% given by
NDHS in 2018.8 It is equally higher than 13.8% reported by Andrea Lanes in Canada,11 2.8%
reported by Pélagie Babakazo in Kinshasha,12 22.7% reported by Melina Mgongo et al in
Tanzania.13 It has been shown that even within the same country and same region different
proportion of exclusive breastfeeding were gotten lower than that gotten from the present study
ranging from 19.0% to 28.5% .14,15,16 These differences might be due to differences in the
population used in the studies, cultural background, or geographical location. When compared
with other values within and outside the country, 33.8% is lower. A community based cross-
sectional study conducted in Ethiopia by Asrat Sonko and Amare Work reported a prevalence
of 70.5%,17 more than half of the participant in a study conducted by Tiras Eshton Nkala and
Sia Emmanueli Msuya in Tanzania was said to had breastfed their babies exclusively,18 two
third of the participants in Ghana practiced EBF.19 There are studies within the country also
where the values are higher than the present study. 9, 20
In the present study, slightly more than one third of the participants 36.2% initiated
breastfeeding within 1 hour of delivering their babies. There are studies within the country
where similar proportion of mothers that initiated breastfeeding within 1 hour and others where
the proportions are more. According to Berde in Nigeria 34.7% of mothers 21 and 38.8% of
mothers based on the findings of Akadri 9 initiated breastfeeding within 1 hour of delivery.
These are comparable to our result. However, among those that reported higher values within
the country are Fehintola et al 40%,15 Atimati et al 44.5%,2 Oche et al 53%,6 and Akinyinka et
al 56.5%. 20 These differences might be as a result of cultural differences as some believe that
colostrum is dirty and should not be given to a child. This believe denies the children of the
benefit of colostrum which is rich in immunoglobulins and predisposes the infants to infection.
Early initiation of breast milk also helps in establishing mother to child bonding.9 This calls for
need to educate mothers on the importance of colostrum.
Reports from other parts of Africa and beyond also revealed that prevalence of early
breastfeeding in this study is low. Kimani-Murage et al in Kenya reported that almost two third
63% of their subjects initiated breastfeeding early.22 Asrat Sonko in Ethiopia found that almost
half of the participant48.6% initiated breastfeeding early17 while Woldeamanue reported 81.8%
from the same country.23 A study from Indonesia revealed that the prevalence of early initiation
of breastfeeding was 52.7%3 and the study in Nepal reported 42.2%.24 The low prevalence of
early breastfeeding initiation in this study may be because more than half of the participants
delivered outside the government hospitals. Training and re-training of health workers on
benefit of exclusive breastfeeding takes place more among those in government hospitals while
other health workers outside government hospital rarely or don’t attend training at all. Some
women decided to deliver in other places outside government hospital because of their
perceived delay in access to prompt care and over dependent of government hospital on family
and relation of patient involvement in their care. Looking at the benefit of early initiation of
breastfeeding in reducing infant mortality, effort should be made by the government in
employing more skilled health workers in the hospitals. 25
In this study being employed and not having anyone around to help at the early part of the
delivery were associated with early initiation of breastfeeding while delivery through cesarean
section and being a primiparous mother were associated with delay in initiating breastfeeding.

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Being employed as a mother in this study was significantly associated with early initiation of
breastfeeding, this is similar to the report from Ahmed et al in Ethiopia,26 though this is in
contrast to another study in Ethiopa.23 This is most also likely because the educated mothers
will be employed, and education has been documented to be significantly associated with early
initiation of breastfeeding by Adhikari et al.25 Educated mothers can get information on
benefits of early initiation of breastfeeding readily on printed materials, radio, television, or
surf for it. They have more access and more understanding of health promotion messages. This
is contradicted by Berde et al in Nigeria that working mothers were less likely to initiate
breastfeeding timely.21 Not having close relatives to assist at initial stage of delivery was
significantly associated with early initiation of breastfeeding. The relatives that assist in this
environment are mostly aged women who traditionally believe that colostrum is dirty and
should not be given. A study conducted Khanal et al in Nepal shew that those that delivered
with traditional birth Attendants initiated breastfeeding late 24 and these traditional birth
attendants were aged women with their belief that colostrum is dirty and should not be given
to newborn. They don’t encourage mothers to give colostrum, so where they are absent the
skilled health workers stay more around to encourage mothers to initiate breastfeeding.24 This
also show the need to educate not just the pregnant women and women of child bearing age
alone but also the aged women need to be educated on benefits of good practice of
breastfeeding.
It has been well documented as found in this study that delivery through cesarean section is
negatively associated with early initiation of breastfeeding.24, 25, 27 When cesarean section is
done due to the anesthetic drug that the mother is given, she might not be fully conscious to
breastfeed or she might be made to lie in a position that may not be conducive for breastfeeding.
Most time baby might be nurse in intensive care unit separate from the mother. Babies of
mothers who had cesarean section were fed with pre lacteal feedings. In this study almost one
third of the babies were given pre lacteal feedings (water, glucose, and artificial milk), majority
gave glucose. 15,17,20 It was found in this study that primiparous mothers had delay in initiating
breastfeeding compared with those having two or more babies who had experience in
breastfeeding. This is similar to other studies within and outside the country.25 This is an
indication that the primiparous women require proper education on breastfeeding during the
ante-natal clinic before delivery.
CONCLUSION
Majority of the mothers were not practicing exclusive breastfeeding and did not initiate
breastfeeding early as shown in this study with prevalence of exclusive breastfeeding and early
initiation of breastfeeding being 36.2% and 33.8% respectively. About 29.3% of the mothers
gave pre-lacteal feeding to their babies. The primiparous women and those that have people to
assist them immediately after delivery were less likely to initiate breastfeeding early from this
study.
RECOMMENDATION
It is recommended that education on benefit of good practice (early initiation and exclusive
breastfeeding) of breastfeeding should be given to pregnant women especially the primiparous
and the aged women that are likely to assist after the delivery by health workers. Government
should have a written breastfeeding policy that should be implemented in the primary health
care centers.

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