Objective: To determine the prevalence of exclusive and continued breastfeeding in an urban setting, and the factors influencing the choice.
Method: The cross-sectional study was conducted from February 1 to August 30, 2018, in Najaf, Iraq, and comprised children aged up to 2 years from 12 randomly selected primary healthcare centres. Data were collected using a predesigned questionnaire that had three parts covering the mother, the child and the demographic variables. Data was analysed using SPSS 20.
Results: Of the 373 subjects, 209(56.0%) were males. The overall mean age was 8.8± 6.2 months (range: 1-23 months), while the mean age of the mothers was 26.5±5.8 years (range: 15-46 years). Children aged <6 months were 169(45.3%), and, among them, exclusive breastfeeding was found in 66(39.1%) cases. There was significant relationship between exclusive breastfeeding and feeding of other siblings (p=0.001), admission to hospital (p=0.02), family support (p=0.009), husband's support (p=0.007). Child sickness in early life also had significant association with exclusive breastfeeding (p<0.05).
Conclusions: The prevalence of exclusive breastfeeding was found within the reported estimate for low- and middle-income countries, but much lower than the World Health Organisation recommendation.
Breastfeeding (BF), according to the World Health Organisation (WHO) is the normal way of providing young infants with nutrients they need for healthy growth and development. Virtually all women can breastfeed provided they have accurate information, the support of their family, healthcare system and society at large.1 Exclusive BF (EBF) means nursing infant for six months without any added food.1 Continuous BF (CBF) complemented with additional food sources is recommended until the second year of life.1
BF has a lot of advantages for both the mother and the infant. For example, EBF between 6 months and 2 years is associated with reduction in infant mortality and morbidity, lower risk of necrotising enterocolitis, and reduced risk of allergic disease, obesity, type 2 diabetes, hypertension and hypercholesterolaemia in later life. There is also evidence in advanced countries that EBF protects against gastrointestinal and respiratory infections.2
Maternal benefits include a lower risk of developing breast and ovarian cancer, adequate weight recovery, and lactation amenorrhoea which could be a natural birth control.3
Globally, only 40% infants receive EBF for the first four months of life, but in Iraq the proportion varies greatly from region to region, like 26.5% in Erbil in the north4 to 49.6% in Babylon in central Iraq.5 Overall, it was 25.8% in 2018 which was lower than the already low global figures.6
The current study was planned to find out EBF and CBF prevalence in an Iraqi city, and the factors influencing the choice.
Subjects and Methods
The cross-sectional study was conducted from February 1 to August 30, 2018, in Najaf, Iraq. After approval from the ethics review committee of the University of Kufa, Iraq, and the Najaf Directorate of Health, the sample size was calculated using the equation:7 n= Z2 p (1-p) / d2 where N was the sample size, z was the statistics corresponding to a level of confidence, p was the expected prevalence, and d was precision. The prevalence was taken as 38%,8 while confidence interval was 95% and precision 5%.
The sample was raised from among children aged under 2 years who attended primary healthcare centres (PHCs) with their mothers either for routine vaccination or for integrated management of neonate and child health (IMNCH).
There were 27 PHCs in Najaf city; 15(55.5%) in the northern district, and 12(44.4%) in the southern. Of them, 12(44.4%) PHCs were randomly selected; 8(66.6%) from the northern district, and 4(33.3%) from the southern.
The subjects were randomly enrolled from the selected health centres as clusters. All children under two years of age were included.
Data was collected after taking informed consent from the parents. Chidren whose parents refused to participate were excluded.
The parents were interviewed using a predesigned questionnaire which was based on literature review.2-5,9It was reviewed by a panel of six experts for validity, and their recommendations were taken into account. The final version consisted of three parts.
The first part related to the mothers' age, job, education level, residence, antenatal care with BF advice, feeding of previous children, medical history interfering with BF and opinions about BF's importance.
The second part of the questionnaire related to children's information, like age, gender, the birth order in the family, type of nutrition, time of starting BF post-delivery, any health problem post-delivery, need for hospital admission and duration of stay as well as the purpose of the current visit.
The third part of the questionnaire related to family, like the income of the family, whether the family was limited or expanded, and the opinion of family members about breastfeeding practices, especially the husbands, the mothers-in-law, mothers and sisters.
The questionnaire was pilot-tested at the Al-Zahraa Teaching Hospital, Najaf, where 9 children aged <2 years were selected from emergency and paediatrics departments. The pilot samples were excluded from the final study sample.
Data was analysed using SPSS 20. Continuous variables were reported as means ± standard deviation (SD), and categorical variables as frequencies and percentages. Inferential analysis was done using chi-square and Fisher's exact tests. P<0.05 was considered statistically significant.
Of the 373 subjects, 209(56.0%) were males. The overall mean age was 8.8±6.2 months (range: 1-23 months), while the mean age of the mothers was 26.5±5.8 years (range: 15-46 years). Majority 365(97.9%) subjects lived in urban areas, 221(59.2%) were from low socioeconomic class, 127(34.0%) were from middle socioeconomic class, and 18(4.8%) were from high socioeconomic class.
Children aged <6 months were 169(45.3%), and, among them, EBF was found in 66(39.1%) cases. The remaining 204(54.69%) children were aged <6 months, and, of them, 105(51.5%) were on CBF plus complementary feeding. The most common cause for PHC visit was for vaccination 266(71.3%), followed by respiratory problems 70(18.8%).
There were significant relationships between EBF, CBF and feeding of other siblings as 31(64.6%) of the infants on EBF had their siblings exclusively breastfed compared to 20(29.9%) from other types of feeding (p=0.001) and 54(79.4%) vs 11(14.1%) (p=0.0001).
Maternal age, education, occupation, residence, receiving counselling during PHC visit, type and place of delivery and any contraindications of breastfeeding showed no significant association with the type of feeding (Table-1).
Regarding the child-related variables, only the admission of the infant during the first few days of life significantly affected the choice of EBF as 24(85.7%) of those who were not admitted were on EBF (p=0.02). Among those aged >6 months, admission to hospital did not affect the choice (Table-2).
EBF increased significantly when husband (p=0.021) and sister (p=0.009) of the mother were supporting, and husband's support also affected CBF (p=0.007) (Table-3).
Among 154(1.3%) mothers choosing bottle-feeding, the commonest cause was milk insufficiency 82(53.2%), followed by mother's work 14(9.1%) and doctor's advice 12(7.8%).
BF is one of the most effective ways to ensure child health and survival. If BF could be increased to near-universal levels, about 820,000 children's lives would be saved every year.9 Globally, only 40% of infants under six months of age receive EBF. In low- and middle-income countries (LMICs), only 37% of children younger than six months of age receive EBF. The WHO recommends EBF for the first six months of life and CBF with appropriate complementary food until two years of age.10
The prevalence of EBF was 39.1% in the current study, which is a bit higher than those reported for LMICs, higher than the prevalence reported previously in Iraq in 2012 (19.6%), and much higher than the prevalence reported by many studies in different countries,11-13The prevalence was lower than that for some other countries.14,15But it is approximately the same as in Saudi Arabia.16 These disparities could be attributed to the differences in socio-demographic features, cultures, methods and sampling techniques used across the different studies.
Many studies have examined the maternal factors that can affect EBF initiation. These factors are different from one study to another, including higher income, maternal education, maternal age, mode of delivery, receiving workshops or BF counselling,17-22as they were significantly associated with starting and continuation of EBF. In the current study, other such relationships could not be proved statistically. This might indicate that high-quality counselling is more important than number of times the mother received counselling. Skin-to-skin contact is less practised in Iraqi hospitals despite WHO recommendations.15,23
In the current study, the most potential factors associated with EBF and CBF were the history of EBF for other siblings, which means that the mother who had experienced BF benefits chose it for her new baby. Admission of the child to the neonatal care unit in the first hours of life, because the child was separated from the mother as she was discharged from hospital a few hours after normal vaginal delivery and a day after caesarean section, usually leaves the mother-in-law to take care of the sick child with her little knowledge about the importance of EBF and the ability of breast milk expression to be used for child feeding.6,11,18,19The family support, especially of the husband and the sister, plays an important role behind EBF.11,24This indicated the need for excessive efforts regarding partners and family education about EBF and involving them in the antenatal care counselling sessions.20,21
The current study revealed no significant association between maternal variables and CBF, which is in contrast to the results from a systematic review of 19 studies.25 Studies have also revealed an association between antenatal counselling and BF prolongation.26 One study demonstrated that vaginal delivery positively related to BF prolongation,27 while another study documented that caesarean section played a role in early BF.28 Mothers working outside the home are less likely to maintain BF,29,30but an East Timor study revealed that mothers working outside were more likely to maintain BF.25In terms of residence and BF maintenance, different findings have been reported, indicating cultural differences.26This difference might reflect the need for more efforts regarding the education of the mothers and their families about the importance and benefits of BF regardless of their age, education, occupation, parity, residence and BF counselling. Also, efforts are also needed to counter the negative attitude among young mothers about the effect of BF on breast contour and shape which, with increasing formula milk advertisements, is causing decrease in the number of mothers who practice EBF and CBF for up to two years.
EBF prevalence was lower than the WHO recommendation. Iraqi women were choosing formula milk regardless of their age, education, occupation, residence, type and place of delivery, children's gender, order and illness. The main determinants for EBF were EBF history, admission of the child to the hospital early in life and family support and encouragement.
Conflict of Interests: None.
Source of Funding: None.
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