Exclusive Breastfeeding Knowledge, Intention to Practice and Predictors among Primiparous Women in Enugu South-East, Nigeria

Breastfeeding is considered as the most complete nutritional source for infants because breast milk contains the essential carbohydrates, fats, proteins, and immunological factors needed for infants to thrive and resist infection in the formative first year of life. Knowledge of exclusive breastfeeding (EBF) among women is essential when promoting optimal breastfeeding practices. This cross-sectional descriptive survey assessed knowledge and intention to practice EBF and its associated factors during pregnancy among primiparous women in selected communities in Enugu State, Nigeria. A total population study that applied inclusion criteria was used to recruit 201 primiparous mothers attending their third trimester antenatal care from selected health facilities in rural and urban communities in Enugu State. A researcher-developed questionnaire was used to collect data on participants' knowledge and intention to practice EBF. Descriptive statistics of frequency, percentage, mean, and standard deviation were used to summarize categorical and continuous variables while Chi-square and Wald statistic tests predicted demographic data associated with knowledge status and intention to practice EBF of the participants. More than half (58.7%) of primiparous mothers had inadequate knowledge of EBF and only 62.7% had intention to exclusively breastfeed for 4–6 months. The Chi-square test result showed significant difference in the participants' place of residence (p = 0.024), EBF knowledge sources (p = 0.001), and EBF knowledge. The Wald statistic in Logistic regression model indicated the coefficient of age (p = 0.026), educational attainment (p = 0.046), EBF knowledge (p = 0.016), and sources of information about EBF (p = 0.027) to be significant predictors of good intention to practise EBF. Poor EBF knowledge and intention to practice in this population may be improved by combining facility-based and in-house methods of breastfeeding counseling, education, and support especially to intending and expectant mothers. Further studies are needed to be done using the multiparous women as well as assessing the effects of in-house EBF supportive-educative intervention to improve breastfeeding outcomes.


Introduction
Breast milk is considered as the most complete nutritional source for infants because it contains the essential fats, carbohydrates, proteins, and immunological factors needed for infants to thrive and resist infection in the formative first year of life [1][2][3]. Based on this, the World Health Organization (WHO) recommends exclusive breastfeeding for the first six months of life and continuation of breastfeeding and adequate complementary foods for up to two years of age or beyond [4]. Exclusive breastfeeding (EBF) is defined as exclusive intake of breast milk by an infant from its mother or wet nurse or expressed milk with addition of no other liquid or solid with the exception of drops or syrups consisting of vitamins, minerals supplements, or medicine and nothing else for the first six months [4]. Despite the awareness being 2 Journal of Pregnancy created by various governments and non-governmental organizations on benefits of EBF, its practice remains lower than the globally recommended standard especially in developing countries [5]. According to WHO's [6] report, only 39% of all infants under six months in developing countries were exclusively breastfed for the first six months of life; 6% of infants were never breastfed; 86% and 68% of infants and children continued breastfeeding at 6-11 months and 12-23 months, respectively. In Nigeria, the Federal Ministry of Health (FMOH) [7] in her document "Saving Newborn lives Maternal and Child Health" reported that Nigeria has one of the lowest EBF rates in the African continent. The recent data indicated that the percentage of infants exclusively breastfed to the age of six months is fluctuating, from 17% in 2003 to 13.1% in 2008 and returned to 17% in 2013, while the proportion of children less than six months who received complementary foods increased from 18% to 35% in 2008 and dropped to 23% in 2013 (Nigerian Demographic & Health Survey [NDHS]) [8]. In addition, the 2013 NDHS results showed that only a third of children were breastfed within one hour of birth. Seventy-four percent of children were breastfed within one day of birth. The prevalence of early initiation of breastfeeding (within one hour) varies according to specific background characteristics, including area of residence (40% in urban areas and 29% in rural areas) [8]. Reports from some centres in Nigeria have given EBF rates at six months as follows: 26.9% in Bayelsa [9]; 58.3% in Port-Harcourt [10]; 19% in Ile-Ife [11]; 21.2% in Enugu [12].
Breastfeeding practices, including initiation and duration, are influenced by multiple interwoven factors [13]. Among these factors, decisions regarding initiation and duration of breastfeeding in low-income countries are influenced by maternal age, education, employment, parity, place of delivery, family pressure, and cultural values. [13][14][15][16][17] In Nigeria, these factors vary widely in various settings and even among women of the same tribe [18]. For instance, some studies have reported that parity was significantly associated with EBF [19], while some others have shown that the practice of EBF increased with increasing age of women [19][20][21]. Chertok et al. [22] also asserted that mother's prenatal intention to breastfeed is a consistently strong predictor of decisions to initiate and sustain exclusive breastfeeding. Besides normative expectations, personal experiences and networks of support have influence on the forms and quality of breastfeeding practices [23]. These factors exert pressure on breastfeeding mothers, thereby making their experience pleasurable or painful within time and space.
In order to achieve the benefits of optimal breastfeeding, more emphasis should be laid on transmitting knowledge to women on the practice of optimal breastfeeding. This is important because the behavior adopted by an individual on EBF is moulded partly by that individual's knowledge of EBF. Despite the available body of knowledge on breastfeeding practices in Nigeria, studies on the level of knowledge and intention to practice EBF and its predictors among primiparous women during pregnancy and how this may influence future optimal breastfeeding practices are limited in Enugu State, Nigeria. Thus, the authors attempted to assess primiparous women's EBF knowledge and intention to practice EBF as well as their associated predictors in selected rural and urban communities in Enugu State, Nigeria.

Methods
The study adopted a cross-sectional descriptive survey design. A total population study that applied inclusion criteria was used to recruit 201 primiparous mothers attending their third trimester antenatal care from selected health facilities popular in obstetric health services in selected rural and urban communities in Enugu State; namely, Comprehensive Health Centre Ahani Achi and Model Comprehensive Health Centre Inyi represent rural community while Mother of Christ Specialist Hospital and Maternity Ogui and Poly Sub-District Hospital Asata represent urban area.
. . Instrument. A researcher-developed questionnaire was used as instrument for data collection. The questionnaire comprised 19-item Antenatal Survey Form (ANSF), used to measure participants' knowledge, and intention to practice EBF. Six items elicited information on demographic characteristics of participants and four close-ended items were on knowledge, while three were on their breastfeeding intention. The instrument was validated by three experts from Department of Nursing Sciences, University of Nigeria, Enugu Campus. The instrument was pilot-tested by administering it to twenty (20) mothers from health facilities with similar characteristics. Data collected were subjected to Cronbach's alpha reliability test which gave a coefficient alpha of 0.87.
. . Ethics Approval. Ethical clearance for the study was obtained from the Ethics and Research Committee of Enugu State Ministry of Health, Enugu Nigeria (Ref. number MH/MSD/EC/0217). Administrative permit was also obtained from the administrators and medical officers' in charge of the selected health facilities used for the study, while signed informed consent was obtained from the participants.
. . Instrument Administration. Four (4) research assistants were recruited and used for data collection exercise after 30-45 minutes discussion of objectives of the study, contents of the instrument, selection of participants, and how to administer the questionnaire and interpretation of the questions in the instrument (where needed). Objectivity and confidentiality on information gathered were emphasized. Data collection was between 9.00am and 12.00pm on Tuesdays and Thursdays which were their antenatal days. The data collection exercise lasted for six months.

. . Categorization of Knowledge of Optimal Breastfeeding
Practices. The assessment of correct knowledge on EBF was based on two variables: (a) understanding that the child is to be given breast milk only (except medications) from birth (at least one hour after birth); (b) identify at least five (5) benefits of EBF; and (c) EBF should be practiced from birth up to 4-6 months of the infant's life. . . Method of Data Analysis. Data collected on demographic characteristics were analyzed descriptively using frequencies, percentages, mean, and standard deviation. Chi-square test of association was used to determine the association between some demographic characteristics of participants and their EBF knowledge while, in some instances, Fishers exact test was reported due to Chi-square assumption violation. A logistic regression was performed on the data to predict the logit of having good intention to practice EBF for both rural and urban women. Probability value < 0.05 was considered statistically significant. All statistical analyses were carried out with the aid of International Business Machine Statistical Package for Social Sciences [IBM SPSS] version 20. Table 1 showed the sociodemographic characteristics of the participants who fit the study inclusion criteria. Their age ranged from 16 to 42 years, with mean and standard deviation of 26.26±4.37. The participants were all Christians 201 (100.0%); predominantly of Ibo ethnic group 199(99.0%) and married 197 (98.0%); 53 (26.4%) of the participants resided in the rural area while 148 (73.6%) resided in the urban area. Most of the participants had completed secondary education 190 (94.5%), while most 166 (82.6%) were gainfully employed outside their homes.

Results
Most of the participants 173 (86.1%) were aware of EBF; 134 (66.7%) had witnessed other mothers breastfed exclusively; 128 (63.7%) could correctly state the meaning of exclusive breastfeeding, when it is commenced, and its duration. Most known benefit of EBF identified by the participants was that of protection against infection and childhood malnutrition 134 (66.7%). Other benefits included the following: breast milk contains right amount of nutrients and water 98 (48.8%) and protection of baby against diarrhoea 88 (43.8%). Generally, majority of the participants 134 (66.7%) had poor knowledge of EBF while only 67 (33.3%) had good knowledge of EBF ( Table 2).
The Chi-square test result showed significant difference in the participants' place of residence (p = 0.024), EBF knowledge sources (p = 0.001), and EBF knowledge while marital status (p = 0.303), educational attainment (p = 0.161), and working status (p = 0.066) showed no significant difference (Table 4). Table 5 showed that although 160 (79.6%) of the women had intention to start practising EBF immediately after birth but their overall intention to practice EBF was poor 115 (57.2%).
The Wald statistic in Logistic regression model indicated the coefficient of age (p = 0.026), educational attainment

Discussion
The participants in this study had similar antenatal demographic characteristics with those that were reported from other health facilities in Nigeria in terms of age, educational attainment, employment status, and marital status. The age range and mean age of the study group (16-42 years and   is low given that most primiparous women had formal education and had attended antenatal clinic more than once. Ordinarily, one would think that the participants' visits and exposure during antenatal clinics would improve their knowledge of EBF. This assumption was, however, not reflected in the findings. It is likely that some of these women might not have accessed antenatal care services where appropriate key messages on EBF are usually delivered or they might be among the group that visit the antenatal clinics after the routine breastfeeding education must have been delivered by the health personnel. These findings are in keeping with other studies [20][21][22][23]. More so, the poor knowledge exhibited by the participants might be associated with their parity since this is the first time they are exposed to experiences of motherhood and quite a good number of them claimed they had not witnessed other mothers breastfeeding exclusively. Results of the study further showed that participants' place of residence (rural versus urban) had significant association with their EBF knowledge. This was obvious as many as 79.2% from rural area had poor knowledge of EBF. Similarly, other sources of information might have influenced urban women's EBF knowledge since their knowledge sources varied widely compared to the rural women. This was also found in a study by Asfaw et al. [24] in Central Ethiopia where 30.4% of women had also received information from the media and 18.4% from their friends. This shows that other sources of communication can be a good source of knowledge on appropriate breastfeeding practices. Thus, the country needs to come up with a communication strategy that will be simple and user friendly, especially for the women in rural communities on EBF in Nigeria. This can then be used both at facilities and in home environment to contribute in improving poor breastfeeding practices and nutrition indicators among infants and children as a whole. Breastfeeding practices are influenced by multiple interwoven factors [13][14][15][16]. Results of the study indicated the coefficient of age (p = 0.026), educational attainment (p = 0.046), EBF knowledge (p = 0.016), and sources of information about EBF (p = 0.027) to be significant predictors of good intention to practise EBF. However, the age group of most mothers in this study was between 21 and 30 years who seem to be more energetic, serious, and more educated and as such more eager to get information that will enhance child survival and development. Experience has also shown that underaged mothers seldom have less time to utilize exclusive breastfeeding unlike matured mothers who appreciate the cordiality that exists between mother and infants as a result of exclusive breastfeeding practices.
The result further indicated that educational background of mothers was found to be a significant predictor of good intention to practise EBF. To a large extent, educated women tend to follow the antenatal instructions to the letter, thereby changing their attitudes towards practice of EBF. This finding agrees with many other studies [23,25] that reported on the influence of mothers' educational level on their decision to exclusively breastfeed. Mothers who had no formal education were more unlikely to practice exclusive breastfeeding than their peers with higher education as mothers with no education tend not to be well informed about the benefits of exclusive breastfeeding as compared to their counterparts with higher education [23]. In addition, EBF knowledge and sources of information about EBF were found to be significant predictors of good intention to practise EBF. This finding is in line with studies by Agho et al. [21] and Qureshi et al. [23] that reported that mothers who accessed antenatal care services during pregnancy were more likely to practice exclusive breastfeeding as appropriate key messages were usually delivered during antenatal care services. Researchers noted that if pregnant women or mothers are educated and counseled properly on the benefits of exclusive breastfeeding, they are more likely to practice EBF than their peers who are not counseled. Similarly, varied sources of information on EBF such as midwives, doctors, friends, media, and peers amongst others had also strengthened their EBF knowledge, thereby influencing their decisions to practice EBF.
The implication of these findings is that, despite the awareness being created by WHO and other organizations on the benefits of EBF, statistics are still indicative of inadequate knowledge and low patronage among women. The authors strongly believe of the need for continuous education and reiteration of the benefits of EBF by midwives and other health workers at every point of contact with mothers so as to improve on their exclusive breastfeeding practice. Establishment of breastfeeding support groups should be encouraged.

Conclusion
Findings of this study revealed that primiparous women's knowledge on EBF and intention to practice it is still low. There was significant difference in the participants' place of residence (rural versus urban), EBF knowledge sources, and EBF knowledge, while the maternal age, educational attainment, EBF knowledge, and sources of information about EBF were found to be significant predictors of good intention to practise EBF.

Data Availability
The raw data used to support the findings of this study are available from the corresponding author upon request.

Additional Points
Recommendations. (i) Emphasis should be laid on making sure that every pregnant woman attending antenatal care receives counseling and support on optimal breastfeeding practices. (ii) Other channels of disseminating information on optimal breastfeeding practices for child growth and survival, such as the social media, should also be used. (iii) Combining facility-based and in-house methods of counseling might help in increasing the number of women who understand the importance of EBF and adhere to optimal breastfeeding. (iv) Intervention programmes on the awareness and benefits of EBF among mothers should be disseminated at the community level and should involve important key players such as community leaders, husbands, mothers-in-law, and grandmothers as they often influence the decision of a mother to exclusively breastfeed. (v) The study was only on primiparous women; thus the findings cannot be generalized for multiparous women. Further studies are needed to be done using the multiparous as well as assessing the effects of in-house EBF supportive-educative intervention to improve breastfeeding outcomes.