Compliance of Mothers to the Breastfeeding Guidelines in Alexandria

The compliance of mothers to the six items related to their practice of the 10 steps of successful breastfeeding (Immediate breastfeeding initiation, rooming in, breast-feeding on demand, avoiding prelacteal feeding, avoiding use of pacifier, and avoiding use of bottles) are of great importance to achieve better breastfeeding outcomes. The objectives of the study were to estimate the extent of compliance of mothers to these items and to identify some factors associated with this compliance. The study was fulfilled through a cross-sectional approach. It was conducted at the MCH and FH centers in Alexandria Governorate. The study included 390 mothers accompanying their breast-fed infants aged 0-12 months to well baby clinics at those health centers. A pre-designed structured interview questionnaire was constructed to collect the data required from mothers. Only 29.8% of mothers started breastfeeding within the 1st hour after labour, 57.2% of them practiced rooming in, and 78.7% of them regulated breastfeeding according to their infants needs. Prelacteal feeding was given to 58.2% of the infants. 22.8% of mothers used pacifiers and 41% used bottles for their infants. Scoring of the overall compliance of mothers to the 6 points related to their breastfeeding practice of the WHO/UNICEF joint statement showed that 24.1% of mothers scored satisfactory level, 41.3% average level while 34.6% scored as low level of compliance. The level of mothers compliance was positively affected by their level of knowledge about breastfeeding and the six items (χ=267.582, p<0.01) and by the increase in the child order (FET=15.618, p<0.01). It was adversely affected by their social level (χ=19.853, p<0.01), education (χ=28.289, p<0.01) and working status (χ=17.439, p<0.01). It was adversely associated with the history of neonatal asphyxia (FET=17.909, p<0.01), the delivery in health settings (FET=44.278, p<0.01), and the delivery by caesarian section (χ=40.193, p<0.01). INTRODUCTION Breastfeeding is the process of feeding an infant with milk produced in a woman’s mammary glands.(1) Breastfeeding has a major role to play in public health, promoting health in both short and long term for baby and mother.(2) Each year new evidence contributes to the knowledge of breastfeeding’s role in the survival, growth, and development of a child as well as the health and well-being of a mother.(3) UNICEF (2007) reported that the child who is breastfed is almost three times more 67 Bull High Inst Public Health Vol. 38 C.1 [2008] likely to survive infancy than a child who is not breastfed.(4) Increasing optimal breastfeeding practices could save as many as 1.5 million infant lives every year.(5) WHO and UNICEF (1989) had issued a joint statement on “Ten Steps to Successful Breastfeeding” to be implemented in every health facility providing maternity care and care for the newborn babies.(6) The compliance of mothers to the items related to their practice of this joint statement (immediate breastfeeding initiation, rooming-in, breastfeeding on demand, avoiding prelacteal feeding, avoiding use of pacifier, and avoiding use of bottles) is of great importance to achieve better breastfeeding outcomes.(7) In the year 1993, training on Baby Friendly Hospital Initiative (BFHI) had commenced in Egypt.(8) Also Ministry of Health and Population (MOHP) since 1997 is implementing a continuous program of inservice training for both physicians and nurses to support and promote good practice in breastfeeding.(9) Despite these mentioned efforts, only 42.9% of babies began breastfeeding within one hour of birth in the year 2005, a marked reduction from the figure of the year 2000 which was 57%. The rate of exclusive breastfeeding (EBF) in the year 2005 was 52.4 percent among infants zero to three months old, which dropped to 38.3 percent among infants zero to five months old. This leaves hundreds of thousands of children vulnerable to disease and death. Around 2.4 percent of all babies in Egypt die in the first month.(10) Low compliance of mothers with breastfeeding recommendations in developing countries was reported.(11) Also several studies in Egypt reported poor performance of both mothers and health care providers on the successful steps to breast feeding.(12-14) The aim of this study is to highlight the influence of breastfeeding promotion and support efforts on mother's compliance to the 6 items related to their


INTRODUCTION
Breastfeeding is the process of feeding an infant with milk produced in a woman's mammary glands. (1)Breastfeeding has a major role to play in public health, promoting health in both short and long term for baby and mother. (2)Each year new evidence contributes to the knowledge of breastfeeding's role in the survival, growth, and development of a child as well as the health and well-being of a mother. (3)ICEF (2007) reported that the child who is breastfed is almost three times more Bull High Inst Public Health Vol.38 C.1 [2008]   likely to survive infancy than a child who is not breastfed. (4)ncreasing optimal breastfeeding practices could save as many as 1.5 million infant lives every year. (5)O and UNICEF (1989) had issued a joint statement on "Ten Steps to Successful Breastfeeding" to be implemented in every health facility providing maternity care and care for the newborn babies. (6)The compliance of mothers to the items related to their practice of this joint statement (immediate breastfeeding initiation, rooming-in, breastfeeding on demand, avoiding prelacteal feeding, avoiding use of pacifier, and avoiding use of bottles) is of great importance to achieve better breastfeeding outcomes. (7) the year 1993, training on Baby Low compliance of mothers with breastfeeding recommendations in developing countries was reported. (11)(14) The aim of this study is to highlight the influence of breastfeeding promotion and support efforts on mother's compliance to the 6 items related to their practice and to identify some factors associated with this compliance.

SUBJECTS AND METHODS
The study was conducted through a cross sectional approach at the Maternal and Child Health center (MCH) and Family Health centers (FH) in Alexandria (Egypt).
It included mothers and their accompanied children aged 0-12 months visiting the well baby clinics at the chosen MCH and FH centers.
The sample size of mothers was calculated using the computer package Epi info 6.Assuming a percentage of exclusive breast-feeding at 6 months of 15.7%, (15) with precision of 3 and confidence level of 95%, the sample size calculated yielded 362 mothers.Three MCH centers and three FH centers were chosen randomly (SRS).
Equal numbers of 65 mothers were selected from each of the chosen centers.
The total study sample was three hundred and ninety mothers An interviewing questionnaire with mothers was designed to collect the following data: -Some socio-demographic data of mothers and family, final assessment of family social level which was calculated according to the modified Fahmy and El-Sherbini social score.

Statistical analysis:
The SPSS 13.0 statistical software package was used for data entry and analysis.Cross tabulation using Chi-square and Fissure Exact test were applied to get statistical significance of relations between variables.Logistic regression using adjusted odd ratio was implemented to get the significance in multi factorial affection.

RESULTS
The (Figure 1) Regarding the compliance of mothers to the six items, the study reveals that only 29.8% of mothers started breastfeeding within the 1st hour after labour while all the others started later.The delay of more than 24 hours occurred among 30.6% of the sample.Only 57.2% of mothers practiced rooming in, while prelacteal feeding was given to 58.2% of their infants and 78.7% of them were regulating breastfeeding according to their infants needs.As regard using artificial teats; 22.8% of mothers were using pacifiers and 41% were using bottles for their infants.Scoring of the overall compliance of mothers to the 6 points related to their breastfeeding practice of the WHO/UNICEF joint statement showed that 24.1% of mothers reached satisfactory level, 41.3% had average level while 34.6% scored low level of compliance (Table 2 and Figure 2).6).breastfeeding initiation, which included 59 studies found that hospital practices that promote early breastfeeding initiation increase breastfeeding duration. (22)In the present study, early breastfeeding within 1 st hour reached 29.8% (Table 2) compared to 43% in Egypt (DHS, 2005) (15) , 42% in Saudi Arabia (23) , 40% in Yemen (24), and 18.3% in Lebanon.compared to 65% in Malawi (27) and 29% in Taiwan. (20)oming-in is one of the ten steps that have been shown to have a positive association with breastfeeding outcomes, a practice which should be encouraged from birth.Mothers who delivered at hospitals allowing rooming-in started breastfeeding within few hours after birth compared with those who delivered at hospitals that did not allow rooming-in. (28)In the present study only 57.2% of the sample of infants were roomed with their mothers (Table 2), compared to 14.9% in Taiwan. (20)This may be referred to the wrong concept among doctors that the infant will be exposed to infection if he is left in his mother ward.

DISCUSSION
Although breastfeeding is almost universally practiced among mothers in most parts of the developing world, the predominant pattern is mixed feeding where an infant is given breast milk and other supplements such as water, infant formula, and local and commercially prepared cereals.Usually this leads to decrease of infant suckling and improper breast milk production and failure of continuation of breastfeeding. (29)In the current study more than half of the infants (58.2%) were given prelacteal feeding, (Table 2).This is in line with EDHS, 2005 (15) (51.3%) and a local study in rural Egypt (Bilbeis) where 60% of infants were given prelacteal feeding. (30)A near figure (65%) was reported in a study in Taiwan. (20)eastfeeding on demand is believed to be the normal way of feeding infants and it is one of the WHO/UNICEF recommendations for successful breastfeeding. (29)There is a variation in breastfeeding patterns between different infants, and from day-to-day. (22)In the current study 78.7% of mothers practiced breastfeeding on demand (Table 2) compared to 93.6% in a study in Alexandria (12) , 93% in Switzerland Geneva (26) , and 75% in western Nigeria. (31)fant pacifiers are artificial molded teats used to calm and sooth babies while they are crying.Daily pacifier use is associated with reduced breastfeeding duration. (32)any lactation consultants believe that the use of pacifiers can cause nipple confusion (infant's difficulty in achieving the correct oral configuration, and suckling pattern necessary for successful breastfeeding).Many early breast-feeding failures are attributed to nipple confusion. (33)In a study in Giza-Egypt use of a pacifier within the first month was associated with cessation of exclusive breastfeeding before 6 months. (34)In the findings of the current study 22.8% of mothers stated that they are using pacifiers (Table 2) compared to 78% in Austria (Graz) (35) , and 51.4% in Taiwan. (20)Less use of pacifiers in the current study compared to Austria and Taiwan may be due to the more emphasis by health providers in advice of mothers to avoid use of pacifier (as noticed in health centers during data collection).
In many of breastfed infants, bottles may be used to provide juice, water, some Bull High Inst Public Health Vol.38 C.1 [2008]   herbals or added breast milk substitute.
Besides the already recognized negative effects, bottle feeding could negatively affect breastfeeding technique.Bottle prohibition was associated with better exclusive breastfeeding (36) In the present study 41% of mothers used bottles in their infants feeding (Table 2).This is most probably due to the predominant use of bottles in providing herbal compounds such as Anise and karaway to calm down their crying infants.In a study in Emirates, nonmilk supplements fed to babies included water, tea, juice, anise, and babunj (local herbal drinks) and the preferred method of feeding the supplements was the feeding bottle. (37) agreement with the previous studies (23,(38)(39)(40) the present study reported that the level of compliance of mothers to (Tables 5 and 6).This is most probably due to better breastfeeding supporting environment in the homes and the better chances for rooming in and early breastfeeding initiation.
) In Iran in the year 2003 (45) caesarian delivery and hospitalization of the infant during the neonatal period was associated with higher rate of bottle feeding compared with newborns who had been delivered normally, discharged early, and nursed at home.
In contrast to the current study, In Croatia (2003), there were significantly greater proportion of women with higher educational level breast-feed their babies, as compared with less educated women. (47)is may be due to more successful health education programs about breastfeeding in Croatia.In Malawi, giving birth outside a health facility was a risk factor for unfavorable breastfeeding outcomes. (27)This may be due to better breastfeeding supporting practice in health facilities in Malawi.

RECOMMENDATIONS
Ministry of Health and Population (MOHP) since 1997 is implementing a continuous program of inservice training for both physicians and nurses to support and promote good practice in breastfeeding. (9)Despite these mentioned efforts, only 42.9% of babies began breastfeeding within one hour of birth in the year 2005, a marked reduction from the figure of the year 2000 which was 57%.The rate of exclusive breastfeeding (EBF) in the year 2005 was 52.4 percent among infants zero to three months old, which dropped to 38.3 percent among infants zero to five months old.This leaves hundreds of thousands of children vulnerable to disease and death.Around 2.4 percent of all babies in Egypt die in the first month.
Many researches worldwide concluded improvement of breastfeeding indicators on applying the 10 steps included in WHO/UNICEF joint statement (1989) for successful breastfeeding.(17,18)Past efforts indicate that improved mothers practices stand out as being the most promising means of reinforcing the prevalence and duration of breastfeeding.(19)In the current study scoring of the overall compliance of mothers to the 6 items related to their breastfeeding practice of the WHO/UNICEF joint statement showed that about one-fourth of mothers reached satisfactory level (Figure2).The situation in Taiwan (2006) was somewhat better, thus the average compliance to those 6 items registered 37.3%.(20)The better compliance in Taiwan is due to implementing the study in baby friendly hospitals.Early initiation and establishment of breastfeeding following birth are crucial for increasing and reinforcing the prevalence and duration of breastfeeding.(19)Breastfeeding within an hour of delivery is associated with the establishment of longer and more successful breastfeeding and ensure that the infant will get the highly nutritional and immunological benefits of colostrum.(21)A systematic review of Bull High Inst Public Health Vol.38 C.1 [2008] (25)  Decreased early breastfeeding initiation in Alexandria according to the current study compared to Saudi Arabia and Yemen may be due to high percentage of hospital deliveries in addition to high proportion of educated women, both was linked with decreased compliance to the six items.(Tables1, 4, and 6).Breastfeeding initiation also differs globally according to the variation in implementation of BFHI, thus in a recent study carried in baby friendly hospitals in Switzerland Geneva, compliance for early breastfeeding initiation reached 93%(26)  , successful breastfeeding recommendations were adversely affected by their education, working state, and social level.The better compliance in mothers of lower social and education level may be in part due to their economic inability to adopt other infant feeding methods other than full breastfeeding.On the other hand the educated working mothers and mothers who attained better social level usually have many commitments and duties which don't leave enough time for them for relaxed nursing of their babies.Also mother compliance improved with the increase in the child order, most probably due to the effect of accumulating experience.Better compliance was also noticed with normal home deliveries and delivery of healthy non-asphyxic newborns.

Figure 1 :Figure 2 :
Figure 1: Distribution of study sample of mothers by their level of knowledge

Table 3
mother work, 14.1%: mother decision without mentioned cause) while health providers were responsible for about 42.7% of the cases (26.4%: doctors advice, 16.3% nurses advice).Concerning the factors affecting mother compliance to the six items, table 4 reveals that the highest proportion of all age groups of mothers demonstrated average compliance level with no significant difference.The improved social level has a 2 =40.193, p<0.01), (Table