Determinants of prelacteal feeding practices among mothers of children aged less than 24 months in Ile-Ife Southwest Nigeria: a community cross-sectional study

Introduction Prelacteal feeding remains an obstacle in achieving the best breastfeeding practices in the country. The growing poor breastfeeding practices are made worse by the continued engagement of the communities in prelacteal feeding practices. This study aimed at assessing the determinants of prelacteal feeding among mothers of children aged less than 24 months in Ile-Ife Southwest, Nigeria. Methods A community-based cross-sectional study that employed quantitative and qualitative methods. Two hundred and fifty-five (255) mother with children aged 0-23 months were recruited into the study using a multistage sampling technique. SPSS version 20 was used for data analysis Descriptive statistics, bivariate and multivariable logistic regression analysis was done. Results In this study, 26.3% of children were given prelacteal feeds. Glucose water (46.3%), sugar water (25.4%) and infant formula (17.9%) were commonly given prelacteal feeds. On multivariate analysis initiating breastfeeding after one hour (Adjusted Odds Ratio (AOR): 2.74, 95% CI 1.43, 5.23), not attending antenatal clinic (AOR = 2.52, 95% CI 1.05, 5.33), delivery via caesarian section 52% (AOR = 1.52, 95 % CI 1.10, 6.34) were associated with increased odds of giving prelacteal feeds. Delivery attended by health professional 25% (AOR = 0.75. 95% CI 0.42, 0.97), highest wealth quintiles 21% (AOR =0.79, 95 % CI 0.51, 0.94) were associated with lowers odds of giving prelacteal feeds. Conclusion Prelacteal feeding was prevalent in the study community and associated with community, individual and health service-related factors. Intervention that strengthens individual and community access to appropriate health information and maternal health services is vital in reducing prelacteal feeding practices.


Introduction
Prelacteal feeding has been linked with poor breastfeeding and health outcomes. It is a documented contributing factor to suboptimal breastfeeding practices. Prelacteal feeding is harmful to the health of newborns because it limits infant's frequency of sucking and exposes them to increased risk of infection [1,2]. According to a recent study, infants who received prelacteal feeding were more likely to be stunted and wasted [1]. The practice of giving prelacteal feeds has been found to be a key determinant of breastfeeding initiation and early cessation of optimal breastfeeding [3]. Prelacteal feed fills the newborn's stomach quickly and interferes with sucking and makes breastfeeding more difficult to establish. This can, in turn, reduce breast milk production and provide an opportunity for early discontinuation of exclusive breastfeeding, and in effect encourage the practice of prelacteal feeding [4]. Prelacteal feeding, therefore, remains a major challenge to optimal breastfeeding and adequate infant nutrition [5].
To achieve child health-related sustainable development goals (SDGs) in the country and also retain the gains of the previous millennium development goals (MDGs) best child health practices such as improved exclusive breastfeeding, with interventions to reduce the prevalence of prelacteal feeding are not only needed but must also be sustained. EBF is associated with greater reductions in infants risks for specific negative health outcomes, including gastrointestinal and respiratory infections [6]. Breastfeeding practices such as early iniatiation and exclusive breastfeeding is the key practice that can reduce child death and morbidity [7,8]. Early initiation of breastfeeding within an hour of delivery enhances mother-infant bonding and creates an opportunity for the newborn to receive colostrum with nutritional and protective benefits [9]. It also promotes effective sucking, with successful establishment and maintenance of breastfeeding throughout infancy [10]. In most countries of sub-Sahara Africa, including Nigeria, prelacteal feeding is still prevalent with a significant proportion of mothers offering their newborns various types of prelacteal feeds. The prelacteal feeding rate in Nigeria remains one of the highest in sub-Sahara Africa. It may be a reason why the country has one of the lowest exclusive breastfeeding rates in sub-Sahara Africa. The World Health Organization (WHO) and United Nations Children's Fund (UNICEF) recommends the avoidance of prelacteal feeding within the first six months of life except it is medically indicated [11,12], because it reduces the chances of a child receiving exclusive breastfeeding. This interaction suggests that the practice of exclusive breastfeeding will be low wherever the prevalence of prelacteal feeding is high as in the case of Nigeria and vice versa. Various prelacteal feeding rate has been reported from different regions of the country. According to the Nigeria Demographic Health survey 2008, geographical variation in the practice of prelacteal feeding ranges from 31% in the Southwest to 79% in the Northeast of the country [13]. Studies have shown that the determinants of prelacteal feeding are multi-factorial in nature and vary across regions and cultures. These factors includes antenatal clinic attendance, mode of delivery, place of delivery, type of birth, wealth index, maternal knowledge and beliefs, birth weight, community awareness, community culture, and regions etc [12,14,15]. According to the NDHS 2013, a significant number of infants were born in home facilities across communities [16] increasing the risk for prelacteal feeding. However, most previous studies on prelacteal feeding in Nigeria were health facility based, and in urban areas [15,17]. There is a need to consider the possible influences that may arise from the community, especially for home and other non-facility deliveries which findings from these previous facility-based studies may not explain. Identifying and understanding the effect of the multiple factors contributing to the continuous practice of prelacteal feeding at the community level in our setting is vital to designing interventions to address these problems. This study intended to fill this gap. The objective of this study was to assess the determinants of prelacteal feeding practices among mothers with children aged less than 24 months in the Ile-Ife, Southwest, Nigeria.

Study sites and period
The study was carried out in Ife Central Local Government Area (LGA), LGA though classified as urban has a mix of rural settlements.

Study design
A community-based cross-sectional study design supplemented with qualitative data collection using focus group discussion and in-depth interview. Sample size and sampling technique. The sample size was determined using a formula for estimation of single population proportion as follows; using the prevalence of prelacteal feeding in Northern Nigeria as 79% [13], 95% level of confidence, 5% margin of error. A minimum sample size of 255 was obtained. A pre-survey was done for this study to determine which households have the targeted mother-child pairs (0-23 months) before the actual study day. From the surveyed household, two hundred and fifty-five (255) mother with children aged 0-23 months were recruited into this study using a multistage sampling technique. Two wards 4 and 5 were randomly selected among the wards in the LGA through simple random sampling. Enumeration Areas (EAs) in the two selected wards were then assessed. Household listing of the selected EAs was done.
Eligible households were then selected through systematic random sampling from all the EAs in the selected wards 4 and 5. One hundred and thirty (130) household were selected in ward 4 while 125 households were selected in ward 5. One mother-child pair (0-23 months) was selected from each household. In households with more than one eligible study subject, only one was selected using simple random selection by balloting system.

Data collection instrument
Quantitative data collection was done using a structured, pretested, interviewer-administered questionnaire. The questionnaire was designed to meet the objective of the study and adapted partly from the one previously used by UNICEF for CIMCI programme in Nigeria [19]. Applicability, acceptability, and validity of the instrument were evaluated during the pretest. Nine trained data collectors were recruited to assist in data collection. Five were for quantitative data collection while four participated in qualitative data collection. Two days of intensive training on the objective of the study, confidentiality of information, and techniques was conducted. The data collectors were given an interview guide during the training to guide data collection activity. Three focus group discussion (FGD) was done. Two among mothers disaggregated by age into young and old mother, one among grandmother aged over 60 years. Two Key in-depth interviews with two representatives of the ward health committee were also conducted.

Study variables and operational definitions
The outcome variable was prelacteal feeding defined in this study as giving anything to drink other than human milk to the index child before the initiation of breastfeeding [5]. This operationalised definition differs from the NDHS definition of giving anything to drink other than breast milk in the first three days after delivery [11,16].
Mothers were asked if they gave any drink other than breast milk to the index child before the initiation of breastfeeding. If the response is "yes" it was coded "1", and if no it was coded as "0".  [4,12,[14][15]. Adjusted odds ratios (AOR) with their 95% confidence interval (CI) were estimated to assess the strength of association while a p-value ‹0.05 was taken as statistically significant.

Qualitative data analysis
Audio recordings of FGD and key in-depth interviews were transcribed by qualitative data experts within 48 hours of the interview to ensure data credibility and dependability. The textual data were then reviewed together and triangulated to reach a better understanding.
A content analysis was used to interpret the findings whereby the transcript was read repeatedly and then categorised into words and phrases to find meaningful relationships between the themes that emerged. The results were presented in conjunction with quantitative data.

Ethical consideration
Ethical clearance was obtained from the Ethics and Research

Committee of Obafemi Awolowo University Teaching Hospitals
Complex. Written informed consent was given by mothers who consented to participate in the study. Permission was also gotten from the local government authorities.

Socio-demographic characteristics
Two hundred and fifty mother-child pairs were involved in the study. Sixty-seven percent attended postnatal/immunization clinic where they again received counseling on breastfeeding (Table 2).

Feeding practices
More than a quarter of mothers (26.3%) reported giving prelacteal feeds to their children. The most common reason for giving prelacteal feeds is the assumption that babies need it for their health (44.8%).

Factors associated with prelacteal feeding
Binary logistic regression analysis revealed that living in the lowest wealth quintiles, delivery assisted by traditional birth attendants, younger mothers age ≤30 years, giving birth through caesarian section, initiating breastfeeding after one hour of delivery and not attending antenatal clinic, and having below secondary education were statistically associated with prelacteal feeding. However, multivariate logistic regression analysis showed that delivery assisted compared to middle or lowest wealth quintiles. Likewise, mothers who did not attend antenatal clinic were two and half times (AOR = 2.52, 95% CI 1.05, 5.33) more likely to practice prelacteal feeding than those who attended antenatal clinic ( Table 4). The odds of initiating prelacteal feeding was 52% (AOR = 1.52, 95% CI 1.10, 6.34) higher among children delivered via cesarean section compared to those delivered through spontaneous vagina delivery

Findings of the qualitative study
Key themes that emerged from the qualitative study revealed that mothers understood and could define what prelacteal feeding means and were highly awareness of exclusive breastfeeding and its benefits.
In spite of this, not all mothers seem to agree fully with the supposed benefits of optimal breastfeeding practices because of beliefs transferred to them by their parents. A 39-year old mother said prelacteal feeding was passed down to us by our parents and the elders cannot be wrong. Orthodox medicine is just eroding how we were nursed (FGD). A 60-year old grandmother said we provide prelacteal feed to newborn to meet their health need. For example to improve their digestion and prevent early constipation. Another grandmother opined that prelacteal foods can prevent infants from disease (FGD). A 25-year old uneducated young mother pointed out that prelacteal feeding is practiced because some children after exclusive breastfeeding refuse to take other meals and as such initiating them on prelacteal feed will help them appreciate early enough that there are foods other than breast milk (FGD). A 51-year old ward health committee representative however differed in opinion from mothers maintaining that perception on prelacteal feeding varies among households. He was of the opinion that although prelacteal feeding is common, the practice is dependent on the influence of members of households. He also emphasised that household with literate grandparents, in-laws, and families with noticeable support for child health may not practice prelacteal feeding because often times their perception of child care differ due to the influence of formal and health education and family support (In-depth interview).

Discussion
Pre-lacteal feeding is widely practiced in Nigeria in spite of its found in a study in Ethiopia [20]. However, a higher prevalence (59%) was reported for the entire country [16]. The lower rate in the study area and the Southwest region of the country may be as a result of higher maternal education, maternal health care utilization and increased delivery in health facilities. The common types of prelacteal feeds in the study community were glucose water, sugar water, infant formula (milk) and plain water. This is similar to findings from previous studies [21,22]. The implication of this is that the types of feed given as prelacteal feeds has not changed just as the practice itself has not reduced significantly. This finding is corroborated by findings from focus group discussion which established that mothers are not unaware of benefits of optimal breastfeeding practices; however, they have a strong belief in practices passed down by their parents and elders in their immediate community. This beliefs influence their perception and contribute to the continuous practice of prelacteal feeding. Behaviour change programmes targeted at reducing the prevalence of prelacteal feeding practices should incorporate not just the dangers of prelacteal feeding but also the risk posed by the types of feeds given to newborns. It should also integrate people in the immediate community of these mothers who influence decisions regarding the care of the newborns such as grandparents, friends of mothers and others. This study found that the odd of prelacteal feeding was lower among mothers who had birth attended by health professional than mothers who had birth attended by traditional birth attendants. This is in keeping with studies from Ethiopia [4] and India [23]. A possible explanation for this is that health professionals are more likely to educate and encourage these mothers on the benefits of optimal breastfeeding and the dangers of prelacteal feeding. In the current study undergoing caesarian section during delivery was significantly associated with a higher likelihood of prelacteal feeding. The higher odd of prelacteal feeding observed among women who had caesarean section compared to spontaneous vaginal deliveries could be linked to the fact that caesarean section often times leads to prolonged maternal-infant separation, pain and discomfort, antibiotics safety concern and occasionally a longer stay in the hospital than anticipated. This finding is in line with reports from previous studies [4,15,24]. Antenatal care visit is the best opportunity to promote skilled attendance at birth and to counsel and educate mothers on essential healthy behaviours like newborn feeding [25]. Mothers who attend the antenatal clinic are more likely to be aware of ideal breastfeeding practices that discourage prelacteal feeding. This was true in this study as mothers who did not attend antenatal clinic were two and half times more likely to practice prelacteal feeding. A high percentage of women in this study attended the antenatal clinic, which suggests that antennal clinic use in the community of study might likely be high. The effect is that the higher the community antenatal clinic use the more likely the chance of developing a norm that discourages prelacteal feeding. Late initiation of breastfeeding was also associated with increased odd of prelacteal feeding. The odds of giving prelacteal feed in this study was approximately three times higher among mothers who initiated breastfeeding after one hour of delivery compared to mothers who did within an hour of delivery. The finding is in congruence with studies done previously [4,14,26]. It is possible that as the interval between delivery and breastfeeding initiation increases, there will be more opportunity for family and cultural influences that promote wrong feeding practices such as prelacteal feeding. In this study, living in the highest wealth quintiles was positively associated with the introduction of prelacteal feeding. The odd of prelacteal feeding was lower among those in the higher wealth quintiles compared to those in the middle or lowest wealth quintiles. The positive effect of wealth in improving mother's health-seeking behaviour and the utilization of maternal health care services may account for this finding. This finding is supported by a report from the key in-depth interview which suggested that households with literate families and noticeable support for child health often do not engage in prelacteal feeding.  [20]; however, it contradicts findings from some other studies [4,12]. The strength of this study draws from the qualitative component which established a strong link between community beliefs, maternal influences and the practice of prelacteal feeding. It also revealed pertinent determinants of prelacteal feeding.
However, the study is not without limitations; the study limitation relates to the fact that the information obtained from the mothers is subject to recall bias. Besides, due to the cross-sectional study design, caution must be exercised in making causal inferences of the identified determinants of prelacteal feeding.

Conclusion
Prelacteal feeding was prevalent in the study community. This high prevalence was significantly associated with maternal, health service and community-related factors such as low household wealth status, delivery through caesarian section, having birth assisted by traditional birth attendants, late initiation of breastfeeding and poor antenatal clinic attendance. Community beliefs and practices was a major underlying factor for prelacteal feeding practice. Intervention that strengthens individual and community access to appropriate health information and maternal health services are necessary for reducing prelacteal feeding practices.
What is known about this topic  Prelacteal feeding has been reported to be highly prevalent and widely practiced in the country;  Regional variations in the prevalence of prelacteal feeding exist in the country.  The study establishes community beliefs and practices as an underlying factor for prelacteal feeding practice.
TO and OO conceived the study, AA participated in its implementation, data analysis, and writing of the final manuscript. All authors read and approved the final version of the manuscript Tables and figure   Table 1: socio-demographic characteristics of mothers of children aged less than 24 months in Ile-Ife Southwest Nigeria (N = 255)    Figure 1: conceptual framework of determinants of prelacteal feeding and interaction with breastfeeding practices