KNOWLEDGE, ATTITUDE AND ADOPTION OF APPROPRIATE FEEDING PRACTICES BY MOTHERS AND ANTHROPOMETRIC INDICES OF THEIR CHILDREN IN AGUATA LOCAL GOVERNMENT AREA OF ANAMBRA STATE, NIGERIA

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ABSTRACT

This study was designed to assess the knowledge, attitude and adoption of appropriate infant feeding practices of mothers and the anthropometric indices of their children. Three hundred and seventy three mothers who attended infant welfare clinics at the three health settings (General hospital Ekwulobia, Primary health care Ekwulobia, and Primary health care Akpo) all in Aguata L.G.A were involved in the study. The study evaluated the nutritional status of the infants in relation to their anthropometric indices. Also infant feeding practices of mothers in the locality was assessed. A validated semi-structured questionnaire by experts at the Department of Home Science, Nutrition and Dietetics, University of Nigeria, Nsukka was used to elicit information on socio-economic characteristics of the mothers and their children. Results showed that age of the mothers involved in the study ranged from less than 20 years to 41 years and above. The mothers were mostly civil servants (29.50%), traders (29.30%), skilled workers (16.90%), housewives (16.60%) and unskilled workers (9.40%). Household size of 3-4 members dominated (38.90%) of population studied. On the average, 67.74% of the mothers had correct knowledge of infant feeding guidelines which means that mothers were knowledgeable on the infant feeding guidelines. Most mothers (67.60%) received information on breastfeeding through the midwives and nurses where they attended antenatal clinic. A total of (47.70%) of the mothers ever adopted exclusive breastfeeding for different periods of time. A total of (43.40%) stopped breastfeeding their babies after 12 months of age followed by (21.70%) who stopped breastfeeding after 15 months of age of the child. Only 19.30% and 13.90% stopped breastfeeding their babies after 9 months and 6 months of age respectively. Anthropometric indices (length and weight) were used to assess the nutritional status of the children. The boys were taller and heavier than the girls in all age groups except age 19-24 months. A total of 22.62% of males and 21.26% of the females were stunted. About 7.54% of the males and 14.37% of the females were wasted. A total of 12.06% males and 7.4% females were undernourished. There was positive and significant (r = 0.7714: P<0.0001) correlation between age and weight of the children as well as their length and age (r = 0.7937: P<0.0001). Breastfeeding was the predominant infant feeding method among the mothers. There was no significant (P>0.05) difference between the weight and length of children fed breast milk only and those fed breast milk plus formula; breast milk and other foods. There was a significant (P<0.05) difference in the length and weight of males and females, within 0-6 months of age while there was no significant (P>0.05) difference in their weight and body mass index (BMI). For those within 7-12 months of age there was no significant (P>0.05) difference in their length, while there was significant (P<0.05) difference in their weight and BMI.

CHAPTER ONE

1.0                                                          INTRODUCTION

Infant feeding comprises breastfeeding and complementary feeding (Ashworth and King, 1994). Appropriate infant feeding is the cornerstone for child’s development. The first two years outside the womb is crucial. It is a period of intensive growth and brain development of an individual. The nutrient requirement of the child is high per unit body weight because of the rapid growth rate (Ene-obong, 2001). The adverse effect of poor feeding will lead to impairment of cognitive development.

            Breastmilk is natural and meets the nutritional needs of the infant in the first six months of life if exclusively given. This was why WHO/UNICEF (1990) advocated that breastfeeding should exclusively be given for six months of life. Human milk is the right food for the young infant and provides all the energy and nutrients that the infant needs for the first six months of life and upto one-third during the second year of life (de Andraca, et al., 1998).

            Breastfeeding is a unique process that provides ideal nutrition for infants and contributes to their healthy growth and development. It has a unique biological and emotional influence on both the mother and the child (WHO/UNICEF, 1990). Armstrong (1995) also stated that it is an unequalled way of providing food for the healthy growth and development of infant.

Breastfeeding has overwhelming advantage everywhere in the world, but especially in developing countries, where hygiene is poor and some cannot afford to buy sufficient formula. Most mothers have no basic education to be able to use formula properly if affordable (Jelliffe and Patrice, 1991). Breastfeeding is the most ancient method of child spacing provided the child is taking breastmilk as required for the day, it causes the menstrual period to stop (lactation amenorrhoea). Kennedy and Visiness (1992); Dada, Akesode, et al.,(2002) reported that breastmilk helps to space children and reduce the risk of ovarian and breast cancer (Lancet, 2002). Breastmilk also increases family and national resources (WHO, 2004). Breastfeeding stimulates bonding between the child and the mother and psychosocial development. It leads to improved nutritional and physical growth, reduced susceptibility to common childhood infections and better resistance to cope with them (Health Canada, 2004). Improve health outcome in infants have long lasting effects throughout lifespan including increased performance and productivity (WHO, 2004). Optimum breastfeeding prevents both under nutrition as well as over-nutrition and provides protection from obesity related diseases.

            A review of evidences have shown that on a population basis, exclusive breastfeeding for the first six months of life is the optimal way of feeding infants (Health Canada,2004). Thereafter, infant should receive complementary foods with continued breastfeeding upto two years of age and beyond (Goldman, 1993; Dewey, et al., 1999).

            Complementary feeding is the transitional period of gradual introduction of solid food or semi-solid food to the infant and this is usually as from six months of life (Malcolm, 1999). The transition from exclusive breastfeeding typically covers the age from 6-18-24 months of age (Pelto, Levitt et al., 2003). Between these period is a critical transition period when the exposure to environmental pathogens are most intense and the likelihood of inadequate nutrient intake most probable (Underwood, 1985). Complementary-feeding should be timely, adequate, and safe and appropriate (WHO,2002). The frequency and amount of food given to the infant should also depend on the age and the need of the infant. This is important to ensure that complementary foods which are often poor do not displace the more nutritive breastmilk in the child’s diet (Cohen et al., 1995).

            Complementary feeding is an action that is largely under the control of the family, although support from the health care provider is essential (SCN,2006). Thus complementary feeding needs to be learned through

behavioural modeling, as well as through the acquisition of knowledge (Pelto et al., 2003).

            Over the centuries, human infants have been fed with their mother’s breastmilk. The development of alternative, milk formula, infant formula, have given contemporary mothers a second choice (Nwachukwu, 1998). Owing to the poor knowledge of composition and production of breastmilk by some mothers, insufficient milk production or weight gain is reason for not exclusively breastfeeding their babies (Nwazor,1996). According to king (1998), mothers resort to early introduction of complementary feeding thereby exposing the infant to diarrhoea, under-nutrition and malnutrition. Lack of support from close female relatives, health workers and pressure of urban life prevent mothers from breastfeeding their babies adequately. Poverty and ignorant, however, may result in nutritionally inadequate complementary foods which could lead to malnutrition and associated increase risk of infection (Ashworth and king., 1994). The level of the mother’s nutritional status which is very low in most cases prevents her from meeting up with the demand made upon her by the suckling baby.

            To this effect, such mothers put up non-challant attitude towards breastfeeding their babies (Azagiro, 2000). Some mothers have poor attitudes and ideas such as colostrum not being good for baby, breastfeeding may spoil a woman’s figure and interfere with her relationship with men and breastfeeding in public is embarrassing which may lead to poor breastfeeding practices and early introduction of complementary food. These have adverse effect on the children if not properly handled (King, 1998).

  1.       Statement of problem

            In Nigeria, Malnutrition is one of the major causes of infant mortality and this usually peaks between 1 – 2 years of life when baby is taken off breastmilk and inappropriate complementary feeding instituted. The nutrient intakes of these babies deteriorate as a result of poor knowledge, attitude, practices and ignorance of most mothers towards adequate nutrient intake. Some believe that the baby can tolerate any food provided the baby is hungry. This results in failure to thrive with resultant high mortality rate. Mother’s poor attitude of complementary-feeding expose babies to so many hazards like malnutrition, infections, and stunted growth, (Filtea and Tomkins, 1994).

Infant feeding practices are influenced by numerous factors such as economic, socio-cultural and biomedical constraints in many areas (Butte, Lopez-Alarcon et al., 2002). As a result of these prevailing factors, the researcher deem it fit to study the knowledge, attitude and adoption of appropriate infant feeding practices among nursing mothers in Aguata.

1.2       Objectives of the study

1.2.1 General objective: The general objective of the study is to asses the knowledge, attitude and adoption of infant feeding practices of mothers and anthropometric indices of their children in Aguata local Government Area.

1.2.2    Specific objectives

The study has the following specific objectives:

i.          to asses knowledge of infant feeding guidelines among mothers in Aguata   Local Government Area.

ii.         to ascertain infant feeding methods adopted and practiced by mothers in the study area.

iii.        to asses mothers attitude towards exclusive breastfeeding.

iv.        Compare feeding methods with anthropometric indices of children 0-2years.

1.3    Significance of study

            The result generated from this study will help mothers improve on their knowledge, attitude and adoption of infant feeding practice. Some of the negative beliefs and attitude of mothers towards infant feeding will be corrected. Depending on the result generated, the health workers will learn good infant feeding practices and the effect of poor practices.

  1.    HYPOTHESIS
  2. More mothers know about correct infant feeding guide-lines (P<0.05).
  3. More mothers adopted exclusive breastfeeding (BMO). More mothers exclusively breastfed their babies for 6 months.
  4. More mothers introduced complementary food at 6 months of age of their children.
  5. More mothers continued breastfeeding after 18 months of age.
  6. Exclusively breastfed children have higher anthropometric indices than the other groups.

CHAPTER TWO

  •                                                 LITERATURE REVIEW

            Poor knowledge, attitudes and practices of infant feeding practices are well known to have adverse consequences on the health and nutritional status of children, when in turn have consequences for the development of the child both physical and mentally. An increase in morbidity in turn impacts heavily on public health expenditure.

2.1       Global Prevalence

            The proportion of women breastfeeding varies widely throughout the world. In 1981, the world health organization reported that in some countries, most mothers’ breastfed for one year but in others this figure was smaller (Malcom, 1999).

            In Nigeria, breastfeeding is a common practice among women. However, the new lifestyle and the emergence of working class mothers have caused a decline in breastfeeding practice. (Labbok et al., 1997; ACC/SCN, 2000). In addition, Nigerian women are familiar with socio-cultural practices such as feeding practices such as feeds and supplements as well as early weaning. These make the acceptance of exclusive breastfeeding difficult. Consequently, the practice of exclusive breastfeeding is low in Nigeria (Labbok et al., 1997; ACC/SCN, 2000) despite the fact many hospitals have benefited from well drawn programmes to improve breastfeeding such as baby friendly hospital initiative (BFHI) and nutrition education and talks (ACN/SCN,2000). According to SCN (2004), 17% of Nigerian woman exclusively breastfed for a period of less than six months while sixty-three (63%) percent and thirty-five (35%) percent breastfed for 6-9 months with complementary feeding and 20-23 months respectively. The median duration is 20% per month. According to Malcolm (1999), in a group of woman in rural Nigeria, 97% were still breastfeeding at one year. Unfortunately the more economically advantaged women in Nigeria and other developing countries followed the western pattern and stopped breastfeeding only a few months or weeks (Malcolm,1999). The attitude of the father and grandmother of the infant is also of great importance in determining whether a woman wills breastfeed her infant. In developed countries, the positive reason’s to breastfeed babies are mainly psychological rather those of safety (Malcolm, 1999).

            In Kosovo, breastfeeding is generally recognized but exclusive breastfeeding is generally low and introduction of complementary feeding is common within first two months of life (Laura and Caroline, 1999). A number of 25% of women start to breastfeed until 24 hours or more after birth. Younger women are breastfeeding for a shorter length of time than their mother did. Although the reason for this was not established (Laura and Caroline,1999). In Bangladesh, it was reported that about 20% of mothers exclusively breastfed for 5 months and 16% of the infants were given bottle feed by the age of one month. In another study conducted in rural Bangladesh, 85% of infants at one month and 30% at six months were breastfed predominantly. The median duration for exclusive breastfeeding is low and has been reported to be 1.5 months in rural Bangladesh, (Shameen et al., 1998). In Sub-Saharan African, 26% of infants fewer than three months of age were exclusively breastfed with median range of 23% and 22% in 1996 and 2001 respectively. Then 68% of infants were introduced to complementary feed at six to nine months (UNICEF, 1997; SCN, 2004). In Mexico, 38% were exclusively breastfed for less than six months, 36% at six to nine months were breastfed with complementary feed and 21% still breastfed at 20-23 months.

            In Georgia, 18% were breastfed at less than six months, 12% were breastfed at 20-23 months. In Turkey, 70% were exclusively breastfed for less than six months, 24% were breastfed with complementary food at 6-9 months while 21% still breastfed at 20-23 months (SCN, 2004).

            In Britain, over the last ten years, there has been increase in the proportion of women initially breastfeeding their infants. The DHSS, (1988) reported that in the early 1980’s, 67% of mothers in England and Wales breastfed initially, and 40% were still breastfeeding at 4 months. These figure were influenced by the socio-economic class of the family, 97% of women in the highest socioeconomic group fed their baby compared with a figure below 50% in a group of less advantaged women.

  • Composition of Breastmilk

            Human milk is nutritionally adequate for the young infant’s needs and, supports growth by itself for upto six months (Malcolm, 1999). Human milk is very different in composition from cow’s milk. A result of previous study examined the composition of human milk compared to that of cow which included the nutritional estimation and microbiological activity as shown in the Tables 2.1. Unless altered, cow’s milk should not be used in infant feeding until the infant is 12 months old because cow’s milk is too high in minerals and protein, and does not contain enough carbohydrate to meet infants’ needs. This may trigger development of diabetes in infants with a genetic factor (Wardlaw, 1999). Composition of breastmilk is not constant between women and some women for different lactating period and even during the day (Barasi, 1997). Beneth and Brown (1996) reported that human milk varies in its composition, maternal nutrition and individual variations. According to Linda (1999), human milk is under utilized resources, as many mothers prefer to use modified cow’s milk formula as source of food of choice for infants. One major reason for under utilization is lack of consistent and accurate information from health care providers because they don’t often understand process of lactation nor cultural factor that may influence a woman not to breastfeed. It is important that health worker in contact with the mothers be knowledgeable about health, nutritional and physiological influences, possible difficulties that may occur and how to over come these difficulties (Linda, 1999).

            Human milk provides sufficient energy and essential micro and macro nutrients for rapid growth and development of the baby during the first six months of life (UNICEF, 2000). It also contains a repertoire of antimicrobial sub-binding proteins and many other substances of indeterminate functions (Garrow and James, 1998).

            The carbohydrate in human milk is mainly lactose and its lactose concentration is greater than cow’s. Lactose accounts for about 38% of total energy in human milk. Lactose enhances the absorption of calcium due to lower pH which results from formation of unabsorbed lactose to lactic acid. The resultant lower pH makes calcium more soluble (Barasi, 1997, Garrow and James, 1998).

            Human milk fat is 98% triacylglycerol and contributes to 50-60% of total milk energy. Although the total fat content of human and cow’s milk are similar, the fatty compositions are quite different. Human milk contains substantial amounts of unsaturated fatty acids particularly oleic acid and linoleic acids (Garrows and James 1998). Digestion and absorption of fat is aided by the presence of lipase within the milk secretion which starts the process of digestion before it reaches the small intenstine (Barasi, 1997). Again human milk fat alphamonoglycerides which is the main products of fat hydrolysis in cows milk (Garrows and James, 1998).

            The proteins in human milk are predominantly whey protein including alpha-lactalbumin, lactoferrin, and various immuonoglobulin. Although lactalbumin is a major source of amino acids, the other whey proteins have non-nutritional role as a protective agents. Immunoglobulin confers immunity and prevents allergic reactions while lactoferrin is bacteriostatic by binding iron and making it unavailable for bacteria which require it for growth. Again casein forms only 30 – 40% of the total protein in human milk whereas it comprises 80% of total protein cow’s milk, casein from tough leathery curds in the stomach, which becomes more difficult to digest (Barasi, 1997; Garrows and James, 1998).

            The vitamin content of human milk is related to the mother’s vitamin status. Generally, the level of water soluble vitamins is adequate. Vitamin E levels tend to be high and vitamin A levels are moderate. Vitamin D and especially vitamin K tend to be low, although deficiency of vitamin D is prevented by giving breastfed infants the vitamin supplements while vitamin K deficiency is prevented by administration of intramuscular injection vitamin K to the new born immediately after birth (Garrows and James, 1998). Human milk contains binding factors folate and vitamin B12 which facilitates their absorption (Barasi, 1997).

            Levels of minerals in human milk are adequate. In addition specific binding factors for iron and zinc have been identified in human milk which makes their absorption much higher from formula (Barasi, 1997). Other important components of human milk include white blood corpuscles and contaminants. The white blood corpuscles are capable of destroying bacteria and producing antibodies and other immune factors such as inferon. Human milk may contain substances passed through the mother (contaminants) such as drugs, alcohol, nicotine and pollutants (Barasi, 1997). Unfortunately too, there is evidence of transmission of variety of viruses including human immuno deficiency virus (WHO, 1998c). The water intake of an exclusively breastfed infant is adequate even in very hot climate and water supplementation is unnecessary (Barasi, 1997; WHO, 1995).