Abstract
Exclusive breastfeeding (EBF) rates are poor in low- and middle-income countries, and according to the Federal Ministry of Health of Nigeria, it is 29% which is below the global target of 70%.
Life decisions are formed plausibly in adolescence, and these are reliant upon information acquired at this stage; however, there is a dearth of information on adolescents’ EBF intentions in community settings. The study sought to assess the intention, knowledge and attitude of adolescents toward exclusive breastfeeding on this basis. The findings of the study indicated gaps in intention, knowledge and attitude, suggesting that interventions should be directed toward this age group to reduce suboptimal feeding practices
The findings suggest that EBF education interventions that commence from adolescence are necessary to promote the practice that is effective in preventing child morbidity and mortality.
Introduction
Breastfeeding is a healthy practice, and understanding the views of adolescents can proffer prompt steps for intervention as suboptimal breastfeeding practices are becoming widespread in Nigeria. This is because the choice to breastfeed is shaped conceivably in adolescence.
Globally, less than 40% of infants aged 0 to 6 months are exclusively breastfed which is way below the 2030 global target of 70%. 1 Findings have indicated that non-exclusive breastfeeding contributes to 11.6% of mortality in children under 5 years of age. 2 Statistics from WHO reveals that low- to middle-income countries have 95% of births to mothers below 20 years of age, and the highest rates occur in sub-Saharan Africa. 3 Nonetheless, optimal breastfeeding has the potential to save over 820,000 children under the age of 5 years each year. 4
In Nigeria, EBF is seemingly low at 17%, and World Bank indicators showed that teenage mothers make up 22.9% of women in Nigeria. 5 This low EBF rate and increase in teenage pregnancy suggest that EBF intention of adolescent needs to be captured. Studies have indicated that having the right information improves knowledge and fosters good attitude, which play a vital role in the intention to breastfeed. Inaccurate information on EBF, age of mothers and inadequate supportive environment from significant others are some factors associated with the practice of EBF.6,7 Being 35 years and older and having an unplanned pregnancy were found to reduce the likelihood of having a strong intention to exclusively breastfeed an infant. 8
In addition, breastfeeding is an internationally recognized and supported practice. WHO recommends breastfeeding exclusively for the first 6 months and afterwards continued for a minimum of 2 years from the child’s birth, with the introduction of complementary foods that are safe, appropriate and adequate from the age of 6 months. 9
These recommendations are due to the established facts of the numerous benefits it has for the newborn as well as the mother. When breastfed as a child, there is lower risk of being overweight or obese, better performance on intelligence tests and higher school attendance. Breastfeeding is also associated with higher income in adult life. 4 The reduction in health costs when a child’s development is improved also contributes to economic gains for individual families as well as at the national level. 10 For the mother, the risk of ovarian and breast cancer is reduced as a result of breastfeeding, and it also enhances child-spacing through a hormonal effect which often induces a lack of menstruation. 4
To make an informed decision, facts are essential. During adolescence, a female child makes several decisions, and the choice to breastfeed in the near future is conceivably shaped. But in sub-Saharan Africa where teenage pregnancy and teenage motherhood is on the rise, there is a dearth of information on the intention of adolescents to exclusively breastfeed (EBF). However, the knowledge and attitude toward breastfeeding of adolescents is an important domain to champion the cause of breastfeeding as a child survival strategy. Therefore, this study sought to assess exclusive breastfeeding intentions, knowledge and attitude among adolescent girls in urban communities in Ibadan, Nigeria.
Methods
Design
The community-based cross-sectional study employed a semi-structured interviewer-administered questionnaire that measured the intention, knowledge and attitude to exclusively breastfeed among 271 Nigerian adolescents aged 15-19 years in urban communities in Ibadan, Nigeria. The sample size for this study was estimated using the Leslie Kish formula using proportions from a previous study among adolescent school girls. Being within the 15- to 19-year age range and never given birth nor breastfed before served as the inclusion criteria for this study. A multi-stage (4-stage) sampling technique was used to select respondents from the communities.
Written informed consent was obtained from respondents aged 18 years and parents/guardians of respondents who were underage, while verbal informed consent was obtained from underage respondents. Prior to this, the field assistants were trained, and the questionnaire, pre-tested and standardized. Descriptive statistics, chi-square test and logistic regression at 5% level of significance were used to analyse data. The study was carried out between May 2019 and January 2020.
Instrument for Data Collection
A validated semi-structured, interviewer-administered questionnaire was utilized to acquire data which was divided into 4 sections. The questionnaire was adapted from previous studies on exclusive breastfeeding and outside the study location; this questionnaire was pre-tested among 26 female adolescents. Reliability co-efficient of .73 was used to judge the questionnaire as being reliable.
The intention of adolescents on breastfeeding was measured with a 10-item question. Responses were classified as agree and disagree. Each response is scored 1, making a total of 10. A score ≤ 5 was regarded as poor, and a score ≥ 6 was regarded as good. A 26-item question was used to measure the knowledge of adolescents on EBF. Responses were classified as yes and no. Each response is scored 1, making a total of 26. A score ≤ 12 was rated as poor and a score ≥ 13 was rated as good. A 13-item question was used to measure the attitude of adolescents on breastfeeding. Each response is scored 1, making a total of 13. A score ≤ 6 was regarded as negative attitude, and a score ≥ 7 was regarded as positive attitude.
Method of Data Collection
The data collection was carried out by the researcher and 3 research assistants. The research assistants were trained prior to the time of the data collection. The criteria for selecting the research assistants were experience in collecting data at community setting, good communication skills, knowledge of research ethics and respect for persons. The questionnaire was serially numbered, and copies of the questionnaire were administered after obtaining informed consent. After the copies of the questionnaire had been filled, the researcher checked for completeness and errors before leaving the field.
Data Analysis
The analysis in descriptive statistics such as mean, median and mode and inferential statistics such as chi-square was computed. The chi-square was used to judge the association of variables. The Wald statistic in logistics regression was used to indicate if the coefficient of certain variables was significant. The results obtained from the Statistical Package for Social Science (SPSS version 21) analysis were summarized and presented in prose, tables and charts.
Results
Respondents’ Socio-Demographic Characteristics (N = 271).
Mean age 17.5 ± 1.3.
Adolescents’ knowledge in the current study toward breastfeeding is not in line with the current international recommendations. Only 22.5% of the respondents had good breastfeeding knowledge. In assessing attitude toward breastfeeding, positive and negative score were not far apart although more of the respondents (50.2%) had positive attitude. However, EBF intention was poor (37.6%) (Table 1).
Test of Hypothesis
Chi-Square Test (X2) was Used in Testing Hypothesis at 95% Confidence Interval (P < .05).
Logistic Regression Model on Intention of Exclusive Breastfeeding.
Predictors: age, religion, education, father’s education and mother’s education, knowledge score and attitude score.
Variable type used: categorical (religion, education, father’s education and mother’s education); numeric (age, knowledge score and attitude score).
Reference category: education (tertiary); father’s education (no formal education) and mother’s education (no formal education).
Discussion
The study assessed the intention of adolescents to breastfeed exclusively, as well as their knowledge and attitude as adequate information before motherhood is liable to improve breastfeeding practice. Breastfeeding is viewed as the public health measure with the most cost-effectiveness, which fundamentally impacts infant morbidity and mortality in developing nations.11,12 Breastfeeding knowledge of younger people has been closely linked with attitude and intention.13,14 Findings from this study showed a significant level of awareness; however, detailed assessment suggested many of the respondents lack adequate knowledge about breastfeeding. This affirms the likelihood noted in a study 15 of a decrease in the extent of Nigerian women with adequate breastfeeding knowledge. It is plausible that suboptimal feeding practices have deep roots due to poorly designed and ineffective educational packages on breastfeeding. Coupled with this are several age-long myths that fuel the poor breastfeeding rates. In the event that this persists, a decrease in ideal breastfeeding practice among Nigerian mothers is anticipated. Nevertheless, this differs from findings in a study where breastfeeding knowledge was high and most of the respondents understood what exclusive breastfeeding was. 15 Additionally, the percentage of respondents with good breastfeeding knowledge was similar to that of Korean undergraduates which was far from average, 16 as well as a study in Nigeria among female students of School of Health Technology, Ilesha. 17
Adolescence howbeit early, the choice to breastfeed is made in this stage and it is exceptionally reliant on the breastfeeding information recieved. 18 The greater part of the respondents in this study concurred that water ought to be introduced to infants before 6 months, and they were of the view that breastfeeding in the general population is humiliating; these were corroborated by other studies.14,19
Furthermore, reasons for favouring breastfeeding included mother-infant bonding, breastfed babies are healthier than formula-fed babies, breast milk is cheaper than formula and benefits of EBF last till adulthood, which are closely related with the findings in the study. 13 Also, it was revealed that more of respondents had positive attitude toward exclusive breastfeeding. This is complemented by a study 18 but in contrast to the study in Rwanda, Ethiopia as well as a study Nigeria with lower percentages.20,21,22
A larger part of this study’s respondents planned to breastfeed later. This is not in congruity with the investigation in Ibadan 14 where less than one-third of the respondents know all that is required to breastfeed their future children.
Although an investigation on intention to breastfeed found that an immense number of the respondents intend to start breastfeeding within the first hour of birth, 23 this current study found otherwise. These results from Nigeria are not in line with the WHO recommendation.
Finally, age played a significant role in respondents’ intention to breastfeed as younger respondents had poorer intention. In respect with religion, Christians had better intention to breastfeed. The fathers’ education and mothers’ education were both instrumental in a good intention to breastfeed. The higher the educational attainments, the better the intention. All of these give clarity on selected areas to target and develop effective educational programmes for adolescents. It is important to identify the potential in identifying adolescents, and work with them to ensure they have all the facts, using health promotion strategies so that they can make an informed decision on breastfeeding by adulthood. For example, fathers’ support toward exclusive breastfeeding (EBF) is becoming recognized as a critical entity for successful EBF in a study that identified the significant effect of a breastfeeding programme on intention. 24 It is also vital to include all other entities essential in achieving optimal breastfeeding.
Limitations
The limitation of this study is that the sample size was not large enough, which reflected in the wider confidence interval. Therefore, further study should be conducted with a larger sample to produce a better estimate of the population parameter, when all other factors are equal.
Conclusion
Majority of adolescents demonstrated poor intention to breastfeeding. The EBF intention was influenced by multiple factors and should be considered in determining the effectiveness of interventions targeting this practice. Therefore, coherent breastfeeding education interventions that commence from adolescence to promote the EBF practice by adulthood are urgently needed to confer the numerous EBF benefits.
Footnotes
Acknowledgements
The authors wish to acknowledge the study participants for participating in the study and Network on Behavioural Research on Child Survival in Nigeria (NETBRECSIN) for the technical support given to this study.
Author Contributions
All the authors conceived the study and participated in research design, data collection, data analysis and interpretation of the results. OAO wrote the draft manuscript with substantial input from MAT and OSA. All authors reviewed the draft and finally approved the manuscript for submission.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.
Ethical Approval
Ethical approval was sought and obtained from the Oyo State Ministry of Health research ethics committee, with Ref No -AD 13/479/1434. Each questionnaire also had written informed consent attached. Identifiers such as names and other information in the research instrument-questionnaire, which can reveal the identity of research participants, were not included to ensure confidentiality.
