DETERMINANT OF EXCLUSIVE BREASTFEEDING AMONG MOTHERS ATTENDING MASAKA REGIONAL REFERRAL HOSPITAL. MASAKA-UGANDA

Introduction:World health organization (WHO) and United Nations international childrens fund (UNICEF) recommend all mothers should initiate breastfeeding immediately with the first hours of delivery, thereafter mothers are encouraged to breastfeed their children for at least six months of life before introducing any form of complementary feeding. it is on this global call to promote meeting up with the target set by UNICEF in 2025, a study was conducted in Uganda to assess the determinant of exclusive breastfeeding among breastfeeding mothers attending Masaka regional referral hospital. Methodology:The study was a descriptive cross-sectional study conducted on 220 consenting breastfeeding mothers. The data from the survey was statistically analyzed using SPSS vs 26 and information was presented in frequency tables, bar, and pie charts. Results:This study showed that the majority of the 220 participants were between the age of 26-30years, 81 (36.8%) with 194 (88.2%) were married and 94 (42.7%) had secondary education. It also showed that 56 (25.5%) did ANC visits more than four times with the majority 151 (68.6%) delivered by spontaneous vaginal delivery. 172 (78.2%) delivered at health facility and stayed at the facility for about 1-2 days. 100% of all babies were healthy and did not report any congenital malformations and 213 (96.8%) have never been admitted for malnutrition. The prevalence of EBF was 65.9%. Variables such as Age of the child, the weight of the child, mothers employment, educational status, and religion were statistically significant at P < 0.005. Conclusions:This study showed that the rate of exclusive breastfeeding among mothers attending Masaka regional referral hospital was generally above the expected target by WHA 2025.Hence strategies of improving health education about the benefits of exclusive breastfeeding to the mother and child should be in place.It is recommended that rigorous interventions can build on this study to achieve the WHO recommendation of all infants should be breastfed exclusively 100%.


Introduction:-
World health organization (WHO) and United Nations international children"s fund (UNICEF) recommend all mothers should initiate breastfeeding immediately with the first hours of delivery, thereafter mothers are encouraged to breastfeed their children for at least six months of life before introducing any form of complementary feeding [1]. A standard universal coverage was set by WHO and UNICEF to be met in developing countries, that all children less than six months should be fed 90% exclusively [1,3].However,in developing countries such as Uganda, has a lot of confounding factors that might be hampering achieving this set target.AshredofRecent evidence indicates that breastfeeding could save over eight hundred thousand children"s life and about two hundred mother"s lives annually [2].Several studies supported the notion that adequate breast milk lowers the body"s risk of sickness from chronic infections and is one of the cost-effective ways of reducing mortality and morbidity among infants. [3]. Its believe that many African mothers breastfeed their babies beyond one year, but only a few practice exclusive breastfeeding [4].
Early introduction of complementary feeding could predispose to risk of diarrhea, malnutrition, and ultimately death [5]. however, if all mothers could practice exclusive breastfeeding properly, approximately 22% of infant death could be prevented [6]. A zimbabwe national statistics survey in 2016 shows that 98% of the children were well fed with breastmilk, only around 40% of these children were exclusively breastfed for six months with any form of complementary food [7]. InTabuk, Saud Arabia a study to determine factors influencing exclusive breastfeeding concluded that programs promoting 6 months of exclusive breastfeeding should target high-risk groups [8]. Two factors identified by this study were modifiable like working mother"s awareness of exclusive breastfeeding duration recommendation and that strategies to improve exclusive breastfeeding should therefore focus on workplace facilities and increasing awareness of the exclusive breastfeeding recommendation [8].
A meta-analysis of studies in four regions including 29 Sub-Sahara Africa (SSA) countries, EBF prevalence ranged from 23.7% in the region of Central Africa to as high as 56.7% in Southern Africa region [9], More recent studies in Uganda report the various prevalence of EBF to be 42.8% by Phoebe et al 2020 slightly below the 2025 projection by UNICEF, two studies show a slightly higher prevalence of EBF 63.3% by Wataka et al, 2021, 67% by Ratib et al, 2019 [10,11,12].However, more studies needed to be conducted to strengthen the existing findings on EBF so the Policymakers can properly plan on appropriate Intervention.Despite the exclusive breastfeeding benefits, the global prevalence remains very low and is estimated at less than 40%, below United Nations Children"s Emergency Funds (UNICEF) set a target of 50% by 2025 [13]). There is insufficient data available on exclusive breastfeeding in Uganda, most especially in the Masaka region. Therefore, it is on this global call to promote meeting up with the target set by UNICEF in 2025, a study was conducted in Uganda to assess the determinant of exclusive breastfeeding among breastfeeding mothersattendingMasaka regional referral hospital.

Study Area
This current study was conducted in Masaka a district in the central region of Uganda.Masaka district is divided into 9 sub-counties, 37 parishes, and 406 villages. The sub counties in Masaka include; Bukakata, Katwe/Butego, Kyanamukaka, Buwunga, Kimanya/Kyabakuza, Mukungwe, Kabonera, Kikingo and Nyendo/Senyange.The total population was estimated to be 251,600 people as per the 2012 census. Administratively the district council is the highest political authority.

Study Design
A descriptive cross-sectional study to assess determinants of exclusive breastfeeding among mothers attending Masaka Regional Referral Hospital.

Target Population
The study population included all mothers who have ever given birth seeking health services from Masaka regional referral hospitals.

Sampling Technique
The convenient sampling method questionnaires were distributed randomly among the clients for selfadministration.

Sample Size Estimation
The ample size was determined using the formula Kish Leslie (1965)

Plans For Data Processing and Analysis
Data analysis and processing will be done immediately after information data entering using, the analysis will be done using SPSS version 26, and Information will be presented into frequency tables, bar graphs, pie charts, and bivariate analysis.

Ethical Considerations
An introductory letter from the Dean of Habib medical School was sought. Permission was also sought from the office of the Medical Director Masaka Regional Referral Hospital. All the information obtained was held with professional confidentiality, the mother"s identity was protected in reporting the results. Table 1 below presents the demographic characteristics of the study respondents where it can be observed that among the total 220 participant"s majority 81(36.8%) are between the age of 26-30 years and the least age group 12(5.5%) being those that fall between 36 years and above, 194 (88.2%) of the respondent reported to be married and just 21(0.6%) respondents reported being single. Nearly half of them 94(42.7%) had secondary education (refer to chart 1 below) and just 13(5.6%) of them are with no formal education, regarding the employment status, onethird of the respondents 75(34.1%) are self-employed of which majority 97(44.1%) are Catholics followed by the Muslims 62(28.2) and while 4 out of every 10 respondents 90(40.9%) resides in the city of Masaka, nearly twoquarter of the total respondents 137/220(62.3%) are ethnically Bagandas.

Maternal factors and mode of delivery
Findings from this study as displayed in table 2 below regarding the maternal factors and mode of delivery showed that 1 out of every 4 respondents 56/220 (25.5%) persistently followed up their antenatal care more than four times and more than three-quarters of them 79(35.9%) visited antenatal clinic four times, regarding the mode of delivery, majority 151(68.6%) responded that they had a vaginal birth, and nearly one-quarter 43(19.5%) of those that underwent a cesarean section started breastfeeding their child for the first time between 1-3 hours after birth and just only one respondent reported to have started breastfeeding following a cesarean section at 24 hours more after birth.Findings regarding the parity of the mothers were reported under this section where it can be realized that most of the mothers 164(74.5%) are not primiparous and regarding their multiparity majority of them have two children and of which more than two-thirds of them 151(68.6%).

Place of delivery
Regarding the place of delivery among mothers in this study, it was reported that more than three-quarters of the mothers 172(78.2%) delivered at the health facility and of which just 7 out of the total 220 mothers (3.2%) delivered through a traditional birth attendant, while the majority of the mothers 84(38.2%) stayed in the health facility for 1-2 days before delivery nearly half of the 96(43.6%) remained at the facility after delivery for less than a day.

Child's factors
Findings from this study regarding the child"s factors showed that more than half of the respondents 127(57.7%) have a child aged less than one month and of which the majority 126(57.3%) are male. Regarding infants" health 100% of babies are healthy with no form of reported congenital abnormalities and most of their child 213(96.8%) have never been admitted to hospital for malnutrition nor had the majority of their child 138(62.7%) suffered any of the listed diseases in the past six months although relatively one-quarter of them 61(27.7%) had suffered respiratory infections. 9 out of every 10 respondent"s child 209(95.0%) do like breast milk and with most of their child 90(40.9%) being averagely rated in their demand for breast milk (see chart 4 below) and regarding their birth weight, 8 out of every child 176/220(80.0%) weighed 2.5-3.5kg at birth.  The exclusive breastfeeding practices among respondents in this study are shown in table 6 below where it is demonstrated that the majority of the mothers 103(46.9%) started breastfeeding their baby as early as 1-3 hours after birth and just only one respondent reported to have started breastfeeding at 24 hours more after birth. Regarding feeding of the baby during the first six months after birth, most of the mothers 145(65.9%) did not feed their baby with anything other than breast milk with just less than 20%(41/220) of the mother reporting to feed her baby with glucose water and nearly half 105(47.7%) of the mothers started to feed their baby with other food substances after 6 months.
The table below shows the bivariate analysis between maternal factors, child"s factors, and exclusive breastfeeding, it can be observed that are no maternal factors associated significantly with exclusive breastfeeding among the respondents (p>0.05) while infants" age is the only child"s factor significantly associated with exclusive breasting (p=0.05). (refer to table 5).

Discussion:-
This study showed that the majority of participants 194 (88.2%) of the respondent reported being married and just 21(0.6%) respondents reported being single. Despite these statistics showing the majority of the mothers were married but it has no impact on their exclusive breastfeeding practices in this study.Mundagowa et al [15] reported similar findings on the association between mother"s marital status and EBF practices, a contrary finding was reported by Alshammari et al.
[16] from their Saudi Arabia study revealed that being married has an impact on the practice of EBF among mothers.Educational status was a predicator to practices of EBF in this study, many of the mothers who had secondary education could be a contributing factor why most mothers with a higher level of education tend to practice Exclusive breastfeeding more than the mothers with low educational status. . According to the study conducted by Mogreet et al, on "Knowledge, attitudes, and determinants of exclusive breastfeeding practice among Ghanaian rural lactating mothers "the mother's age range is 26-30 years which also correspond with this our study that reveals the majority of the respondents 81(36.8%) are between the age of 26-30 years and the least age group 12(5.5%) being those that falls between 36 years and above [2].
The employment status of the mothers was a predictor ofEBFpractice, it was concluded from this study that selfemployed mothers are more compliant to EBF practice as compared to others who are not self-employed. This could also mean self-employed mothers have freedom and are more attached to their children since they have no workplace rules that might hinder the proper practices of EBF. This finding was in line with Wataka et al. [18] in Uganda and Alshammari et al [16] from Saudi Arabia, that shows employment level was associated with EBF practices among mothers, on contrary studies by Um et al. [20] in Cambodiaand Mundagowa et al [15] revealed no significant association between EBF and mother"s employment status. Religion belief of the mothers was a predictor of EBF and also play an important role in mother"s practices of EBF, the religious portfolio of the mothers has 948 influenced their decision on adopting the practices of EBF most especially the Catholic groups followed by Muslim groups of all the mothers tends to practice EBF more than other mothers of different religious beliefs. Similar studies by Wataka et al. [11] shows a statistical association between the region and EBF practice with catholic being the highest religious as compared to other religion, although as a similar finding by Adepoju et al. [18] from Nigeria study revealed region as a predictor of EBF but more predominant among Muslim of that region as compare to catholic noted from this study. Despite most of the mothers stay in the city of Masaka and they are of predominantly Bagandan"s Ethnic group, findings from this study show they have no impact on the mother"s practices of EBF.
The prevalence of exclusive breastfeeding was 65.9%, which implies almost all the mother's practice EBF and this was traced back to their previous history of breastfeeding with previous child/children. Mothers who had a history of exclusive breastfeeding which were 151(68.6%) with the other children had a higher chance of also practicing exclusive breastfeeding with also the current child. Also, mothers were reported to breastfeed their child in the first hours of delivery, and the rate drops as not all the mothers practice exclusive breastfeeding. The World Health Assembly (WHA) in 2012 set a global target to increase the rate of Exclusive Breastfeeding in the first 6 months up to at least 50% by 2025 [1]. The results of our study shows (65.9% EBF rate) indicated that the WHA target has been met in Masaka Region, Uganda. However, it is still far below the widely ""Universal coverage"" target that was recommended by WHO/UNICEF that there should be 90% EBF in children less than 6 months in developing countries including Uganda [26]. This also showed that mothers who had more than four ANC visit 79 (35.9%) followed by those who had four ANC visits 56 (25.5%) with which majority 151 (68.6%) had a vaginal birth and 42 (19.5%) underwent cesarean section with 43(19.5%) started breastfeeding between 1-3 hours after cesarean section. This study shows that mothers who delivered at the health facility were 172 (78.2%) and those who delivered at home were 41 (18.6%) having 96 (43.6%) of them staying less than 1 day in the health facility. This shows that majority of mothers who attended ANC visits and who delivered in the health facility had a high likelihood of practicing exclusive breastfeeding. Also, research findings revealed that the majority of women delivered in health facilities increasing likely hood of being taught by health professional attendants post-Nataly on how to position the baby's whole body close to the body to enhance proper milk flow. However, all the maternal factors though seem to contribute to the mother"s adherence and proper practice of EBF were not a significant predictor of EBF practice in this study. Finding from this study was inconsistent with a report from Wataka et al [11] [24]from Nigeria all shows an association between EBF and ANC visitations among the mothers.
The place of delivery among mothers in this study, it was reported that more than three-quarters of the mothers delivered at the health facility and of which just 7 out of the total 220 mothers delivered through a traditional birth attendant, while the majority of the mothers 84(38.2%) stayed in the health facility for 1-2 days before delivery nearly half of them remained at the facility after delivery for less than a day. As expected that mothers who undergo hospital delivery will be expected to be more compliant to EBF as proper counseling will be given by the healthcare workers. Mothers who deliver at Hospital havethe likelihood to be influenced towards their attitude to proper practices of EBF as compare to those who deliver at home and TBA. However, all the place of delivery variables has no statistical association with the practices of EBF. This study was in line with findings from Somalia by Abdiasis et al. [23], and Uganda by Wataka et al.
[11] which also shows no statistical significance between the EBF and place of delivery among mothers.
Findings from this study regarding the child"s factors showed that more than half of the respondents 127(57.7%) have a child aged less than one month and of which the majority 126(57.3%) are male. Arising from this study we are unable to establish a relationship between the EBF practices and the gender of the child, as we reported more males than females. However, the child"s age was a predictor to EBFpractice in this study. A similar study by Tsegawet al, also reported a significant association between the age of infant and EBF with the gender of the infant as well, their findings were slightly different from this study which indicted only age as a predictor of EBF among 949 mothers [25]. It was also reported from this current study factors like mother"s employment statutes and religion could also be a confounder for adequate practice EBF to children before they are introduced to complimentary food. This study presents findings on infants" health, 100% of babies are healthy with no form of reported congenital abnormalities and most of their children (96.8%) have never been admitted in hospital for malnutrition nor had the majority of their child (62.7%) suffered any of the listed diseases in the past six months. This could also contribute to the high prevalence of EBF among mothers since the majority of their children are healthy for the first six months, meaning they are psychologically stable to adequate practice EBF, although not statistically proven to be significant. Child"s desire for breastfeeding was found to be very high in this study and this was also proportional to the weight of the children reported in this study with 80% of children weighing 2.5-3.5kg at birth. As expected, a child"s continuous desire for breastmilk and their body weight was to be a predictor of EBF, since we believe children of bigger weight are likely to desire breastmilk more than a child"s or low weight. It"s only the child"s weight at birth that was statistically significant to the practices of EBF among mothers. Some findings from different studies agreed with the findings of this study and some disagreed based on their findings. Tsegaw et al.
[25] revealed from their study that child"s weight was not associated with the practice of EBF as contrary to our finding from this study, Um et al.
[17] also reported similar findings to this study showing the age of infant and weight at birth of infant related to EBF practices among mothers, they also revealed an association between the infant sex not statistically significant to practices of EBF among mothers.

Conclusion:-
Most of the mothers that participated in this study were married, the majority employed with a special place for breastfeeding provided at work, most attained a formal education and moat fall in the appropriate childbearing age group of 26-30, most were residents of Masaka city and religion did not influence the outcomes of the study. It was concluded from this study that the EBF prevalence of 65.9% was very high even above the set target by WHO and UNICEF to achieve by 2025. It is important to strengthen EBF practices among mothers to achieve 100% EBF so that we can meet the 70% target by 2030 and this is key in fulling the goals of Sustainable Development Goals number 3 (SDGs 3) The high prevalence from this study was related to some factors as a determinant of EBF among the mothers which are the mother"s religion, educational level, employment status. Factors like child"s age and child"s birth was also a predictor to practice of EBF among mother in this study. This study showed that mothers who attended antenatal care services and those that delivered from health facilities practiced exclusive breastfeeding more than the alternative due to their information from the health facility. Finally, findings from this study were not that different from findings from studies in Uganda and outside Uganda, so this finding from this study will guide the policymakers to focus more on the intervention that"s most importantly mother"s inclusive, and not forgetting roles that place of delivery plays in the adoption and practices of EBF.