TOPIC: AWARENESS AND PERCEPTION OF EXCLUSIVE BREASTFEEDING AS A

BIRTH CONTROL METHOD AMONG PREGNANT WOMEN ATTENDING

CHAPTER TWO

LITERATURE REVIEW

2.1. Definition of Breastfeeding

Breastfeeding according to WHO is the normal way of providing young infants with the

nutrients they need for healthy growth and development, using milk produced from the

mother’s mammary glands. Establishing good breastfeeding practices in the first day after

birth is critical in successful breastfeeding. This can be achieved if mother is physically and

psychologically prepared for birth, is informed, supported and confident that she can

exclusively breastfeed for six months and thereafter for two years or more(Chaudhary, Shah,

& Raja, 2011). The Innocenti Declaration of August, 1990, in Florence, Italy, presents

breastfeeding as a global goal for optimal maternal and child health nutrition and that all

women should be enabled to practice exclusive breastfeeding and all infants should be fed

exclusively on the breast milk from birth to six months of age(Joshi et al., 2014).

2.2. Exclusive Breastfeeding

Exclusive Breastfeeding (EBF) as defined by World Health Organization (WHO) is the

feeding of infants on breast milk alone from birth to six months without the addition of water

or other foods, be it solid or liquid (WHO, 2015). The health of the newborn depends on the

feeding practice adopted by the mother and family. Exclusive Breast Feeding for the first six

months is the optimal and if continued for two years or more, gives the child a good start of

life. Throughout the world, in developed and developing countries alike, inappropriate feeding
leading to poor infant nutrition is a significant problem affecting socio- economic progress in

general (Joshi et al., 2014).

2.3 Benefits of Exclusive Breastfeeding

Breastfeeding continues to serve as an appropriate method through which newborns are

offered essential nutrients necessary for optimal growth and intellectual development. Breast

milk is regarded as a perfect, natural and protective food for newborns. Exclusive

breastfeeding helps reduce mortality and morbidity which significantly improve public health

(Brülde & Dawson, 2011). In a study byVennemann et al. (2009), breastfeeding was found to

be protective against sudden infant death syndrome by reducing the risk by 50% at all ages

during infancy; this benefit has been reported to exhibit dose-response relationship, where

health gained increases with increase in duration and exclusivity. Infants when exclusively

breastfed for the optimal duration of six months are significantly protected against the major

childhood disease conditions such as diarrhoea, gastrointestinal tract infection, allergic

diseases, diabetes, obesity, childhood leukemia and lymphoma, inflammatory and bowel

disease (Eidelman, 2012). Brülde and Dawson (2011), also reported that the risk of

hospitalization for lower respiratory tract infections during the first year of life of infants is

reduced by 72% when they are exclusively breastfed.

Finally, EBF is regarded as imperative for infants’ survival. The WHO reported that out of the

6.9 million under five children who were reported dead globally in 2011, an estimated

1 million lives could have been saved by practices including exclusive breastfeeding

(Eidelman, 2012). Consequently, the WHO and UNICEF in 1990 have recommended

exclusive

breastfeeding for six months, followed by introduction of complementary foods and continued

breastfeeding for 24 months or more(WHO, 2015)

2.4 Importance of colostrum to the baby

immune and growth factors which help in the development of immunity in the newborn.

These growth factors act as natural anti-microbial agents to actively stimulate the maturation

of the baby’s immune system ((Uruakpa Ismond and Akobundu, 2002; Kumar et al 2016). In

addition to immune support provision, it has a significant muscular and skeletal repair and

growth factors that are essential for muscle and cartilage repair (Uruakpa Ismond and

Akobundu, 2002; Kumar et al 2016). Furthermore, colostrum growth factors aid in wound

healing with practical effects on the healing of the umbilical cord after detachment from the

mother (Uruakpa Ismond and Akobundu, 2002; Kumar et al 2016). Finally, colostrum growth

factors have multiple regenerative effects that extend to all structural body cells, such as the

gut and also help in reducing inflammation and illness in a baby..

2.5 Exclusive breastfeeding in the developing world

In recognition of the essential role of exclusive breastfeeding in the health and growth of

children, a lot of effort has gone into scaling up the rates in developing countries where

incidence of child malnutrition and mortality is still high. The successes in increasing the

levels of EBF have rather been modest. In an analysis of data on EBF from 38 developing

countries between 1990 and 2000, Labbok, Wardlaw, Blanc, Clark, and Terreri (2006)

reported an increase EBF rate from 46% to 53% among infants younger than 4 months and

from 34% to

39% for those younger than 6 months. Higher increment is often found in urban areas (30% to

46%) than rural ones (42% to 48%). Although there were increases in all the regions studied,

the Middle East and North Africa (29% to 34%), South Asia (49% to 56%), East Asia/Pacific

(57% to 65%); the most significant increment, however, was found in Sub-Saharan Africa

where the rate doubled from 18% in 1990 to 38% in the year 2000.
2.6. Factors influencing the practice of Exclusive Breastfeeding

Determinants of EBF are the factors or conditions that could lead to changes in the practice,

encourage or impede successful implementation of EBF. The extent to which these

determinants or factors affect EBF is fairly complex and varies from one country to another

and/or between different groups in the same country (Monebenimp et al., 2013) Some are

biological and beyond women’s control such as breast engorgement and nipple problems

while others are combinations of economic, environmental, cultural and social. Variables and

factors that may influence successful initiation and continuation are different and include the

social and demographic background of the mother, individual characteristics, insufficient milk

supply, infant and maternal health problems, parity, method of delivery, maternal interest

towards breastfeeding and previous lactation experience(Nafee Elsayed & Al-Dossary, 2016)

Factors affecting exclusive breastfeeding among Women in Muheza District Tanga was

investigated in Northeastern Tanzania, The results showed that the prevalence of exclusive

breast feeding was 24.1%. The perception that mothers’ breast milk is insufficient for child’s

growth, child being thirsty and the need to introduce herbal medicine for cultural purposes

were among the important factors for early mixed feeding. The results further revealed that

advanced maternal age (OR 2.6; 95 % CI 1.18-5.59) and knowledge on EBF duration and

advantages (OR 2.2; 95 % CI 1.2-3.8) remained significantly associated with Exclusive

Brestfeeding (Mgongo, Mosha, Uriyo, Msuya, & Stray-Pedersen, 2013). Another study

conducted in Ibadan, Nigeria revealed that older mothers aged 35-49 years and women with

good knowledge on Exclusive Breastfeeding had higher prevalence of EBF practice. This

study also showed that the nursing mothers had a strong belief that breast milk alone for the

first 6 months of infant life was not enough for child growth (Nkala & Msuya, 2011).

A study conducted among nursing mothers in India, also revealed that nursing mothers with

good knowledge about the required duration and advantages of EBF had increased odds of
practicing EBF of infants compared to those with low knowledge(Shirima, Greiner, Kylberg,

& Gebre-Medhin, 2001). The findings of these studies are indications that, innovative

strategies to increase women’s awareness and knowledge on exclusive breastfeeding in

general are needed outside the usual facility channel. One effective strategy that can be

considered would be the use of EBF promotion peer counselors in a community or forming

women’s groups to educate the nursing mothers on the importance of exclusive breastfeeding.

2.6.1 Demographic Factors

One significant demographic characteristic that influences exclusive breastfeeding in infants is

maternal age. Most studies have found significant association with EBF among young

mothers than older nursing mothers (Monebenimp et al., 2013). However, other findings also

had a contrary view that showed that maternal age was not associated with EBF practice

(Nafee Elsayed & Al-Dossary, 2016).Therefore more effort should be targeted to both young

and older mothers during intervention to promote EBF. Other socio demographic

characteristics such as marital status and maternal level of education have also shown

association with EBF practice in Tanzania, Uganda and Norway(Aarts et al., 2000).

A study by Pérez-Escamilla and Bermúdez (2012) also revealed that planning on EBF

duration, maternal unemployment, hospital delivery facilities that had breastfeeding

promotion services were positively associated with Exclusive breast feeding in three Latin

American countries. A similar study to assess factors associated with EBF in Accra, Ghana,

by Aidam, Perez-Escamilla, Lartey, and Aidam (2005), reported delivery at

hospital/polyclinic, prior intention or planned EBF at birth, higher education, socioeconomic

status, and positive attitudes towards EBF as the most essential support factors for exclusive

breastfeeding.

2.6.2 Cultural Factors

breast feeding. While some religious and cultural beliefs about breastfeeding seem

entrenched, important family actors and religious leaders if properly educated about EBF

could be used to modify and/or discourage such practices that involve feeding newborns with

herbal teas and ritual concoctions. One of the cultural believes about breastfeeding among

nursing mothers is the belief that a drop of breast milk on a baby’s penis will lead to

impotency if it happens before the baby’s seven birth day(Aborigo et al., 2012).

2.6.3 Perceived Insufficiency of Breast Milk as complete food

The perception of the inability to produce adequate amounts of breast milk especially in the

case of multiple births is a major challenge in the quest to improve EBF rates. Some mothers

find it difficult to believe that it is possible for their babies to survive on only breast milk in

the first 6 months of life without supplementing it with any other food or drink including

water.

Persistent crying of the babies even after they have been breastfed usually suggests to them

that the babies are still hungry (Ukegbu, Ukegbu, Onyeonoro, & Ubajaka, 2011). This

perception of breast milk insufficiency which could frustrate the mother or caregiver and even

other members of the family is likely to contribute to early breastfeeding cessation or shorter

EBF duration (Fjeld et al., 2008) A study among peri urban women in Ghana to identify

perceived incentives and barriers to exclusive breastfeeding reported that perceived milk

insufficiency was one of the main factors preventing the achievement of optimum EBF rates

(Otoo, Lartey, & Pérez-Escamilla, 2009). In a related study in nearby Nigeria, results of focus

group discussions among women with infants between one and six months revealed that many

of the participants reported inadequate production of breast milk as a justification for

introducing other complementary foods (Ukegbu et al., 2011).

2.7 Mother’s perception of insufficient breast milk

as the best feeding method for newborns. This, to a large extent, has been inspired by

mounting scientific evidence on the importance of exclusive breastfeeding in reducing infant

morbidity and mortality (Sokol, Clark, & Aguayo, 2008). However, efforts to promote EBF to

save the lives of millions of children all over the world have not been smooth. In Ghana, EBF

rates dropped drastically from 63.7 percent in 2008 to 46 percent in 2011 and continue to drop

to 40 percent in 2017(GSS, 2011, 2018; G. GSS, MACRO, ICF, 2009). A lot of factors have

been associated with generally low rate of EBF as explained in Section 2.5. In a research to

examine the perceived incentives and barriers to EBF among peri-urban Ghanaian women,

Otoo et al. (2009) found that supposed milk insufficiency, family pressure, breast and nipple

problems, and maternal employment were the factors that were serving as barriers to

Exclusive Breastfeeding. The impact of mother’s perception of insufficient breast milk and

others on EBF though has been studied by some researchers but has not received much

attention like other challenges (Mnyani et al., 2016; Radwan & Sapsford, 2016; Zvinavashe,

Haruzivishe, & Ndaimani). Anecdotal evidence has shown that the impact of these

perceptions on EBF have been enormous. Gatti (2008), found that a lot of women discontinue

breastfeeding during the first few weeks of the post‐ partum period because of perception of

insufficient breast milk and approximately 35% of all women who wean early report

insufficient breast milk as the primary reason. Schluter, Carter, and Percival (2006) Indicated

in their study that the rates of perceived insufficient breastmilk was 30 percent among women

who wean their babies early.