THE ATTITUDE OF WORKING CLASS MOTHERS TOWARDS EXCLUSIVE BREASTFEEDING IN KARU LGA NASARAWA STATE.

THE ATTITUDE OF WORKING CLASS MOTHERS TOWARDS EXCLUSIVE BREASTFEEDING IN KARU LGA NASARAWA STATE. Abstract: The study on working mothers attitude and practice of exclusive breastfeeding in KARU. The respondents were selected through simple random sampling. In all a total of 324 were sample for the study. Data was collected randomly from various immunization clinics in KARU, and analyzed using simple percentage methods. The findings showed that the variables like mothers level of knowledge, mother's attitude towards exclusive breastfeeding, mothers, level of education among others were all significant to their practice of exclusive breastfeeding, while cultural beliefs are not associated with exclusive breastfeeding practice. In conclusion, the study recommended for better practice of exclusive breastfeeding. More education for mother's and the general public on the benefits and need for exclusive breastfeeding. Also the extension of maternity leave to enable other's have enough time to practice exclusive breastfeeding, and provision of creches in all offices to enable working mothers breastfeed their babies properly and teaching of mothers ways of expressing of o breast milk and storage of expressed breast milk so as to improve the rate of exclusive breastfeeding practice by working class mothers and the society at large. Keywords: Working-Mother, Attitude, Practices, Exclusive-Breastfeeding, KARU NASARAWA STATE. CHAPTER ONE 1.0 INTRODUCTION Exclusive breastfeeding has been defined as feeding of an infant with breast milk only without giving any other foods, not even water (Jolly, 2008). The definition allows for prescribed medicines, immunizations, vitamins and mineral supplements. Breastfeeding as a practice was recommended by WHO (2001), for optimal feeding (i.e. exclusive breast feeding for the first 6 months and continued breastfeeding for up to 2 years, with the introduction of other foods). Breastfeeding is a natural process of infant feeding involving two main methods; exclusive and partial with the latter being trendiest. Nevertheless, exclusivity is the absolute and suitable scheme with finest domino effect. However, a good mental, emotional and physical collaboration between the mother and her newborn for desired outcome (Khresheh 2011). Breast milk consists of basic nutrients containing water 87.8%, Lactose 7.0%, Fat 3.5%, proteins 1.5%, Salt 0.2%. However, presence of minerals fulfills micronutrient needs and maternal antibodies improves the immune system inhibiting infantile infections like gastrointestinal, respiratory and skin infections and increases physical and neurological growth of the baby. There is increased production of hormones that are responsible for uterine contraction, preventing hemorrhage and maternal mortality. Lactational amenorrhea is mentioned as a natural contraceptive benefactor following exclusivity. On the other hand, breast cancer and ovarian cancer risk prospects are reduced with weight loss preventing early cardiac morbidity and mortality. (Fairbrother & Stanger-Ross 2009.) During 1940s, exclusive breastfeeding was a communal tradition in all corners of the globe; subsequent to the World War II the ritual instigated to diminish and converted to modern trend in the use of fabricated formula milk particularly in the western world in contemporary eras. The nutrients become inevitable as it started to become widespread despite the advice and presage from World Health Organization (WHO) which recommends exclusive infant breastfeeding for the first six months of life and continuing up to two years of age and beyond United Nations Children’s Fund (UNICEF) and Baby Friendly Organization in order to restore the Primitive Tradition. (Coates 2007.) Essentially, mother's milk has antibodies which are not present in infant formula. These antibodies are what protect the body and the boost the immune system of infant to enable them fight disease. The human milk in the right proportion also helps in robust and all round development of re infant (Jones, 1993: Tiwari, Zahariya and 2008). 1.1 Background Breastfeeding is the act of milk transference from mother to baby that is needed for the survival and healthy growth of the baby into an adult. Breastfeeding creates an inimitable psychosocial bond between the mother and baby, enhances modest cognitive development and it is the underpinning of the infant’s wellbeing in the first year of life even into the second year of life with appropriate complementary foods from 6 months. Furthermore, breastfeeding reduces the risk of neonatal complications, respiratory and other varieties of illnesses. Based on anecdotal and empirical evidence on the benefits of breastfeeding to the mother and baby, the World Health Organization (WHO) has recommended 2 year breastfeeding; first 6 months exclusive breastfeeding; more than 8 times breastfeeding of the baby per day in the first 3 months of an infant’s life. The WHO and the United Nations Children’s Fund (UNICEF) global effort to implement practices that protect, promote and support breastfeeding through the Baby-Friendly Hospital Initiative has recorded attendant successes. However, a gamut of factors not limited to race and cultural beliefs, maternal characteristics, infant health problems, socio-economic status and some psychosocial factors may hamper the full realization of the baby-friendly initiative. Information about the beliefs and knowledge that may constitute barriers and in turn influence practices are needed in order to optimally utilize the benefits of the baby-friendly initiative. Consequently, a number of studies have assessed knowledge, attitude and practice of breastfeeding in different parts of the world; however, such studies are limited among Nigerian mothers. Furthermore, there is an apparent dearth of empirical data on breastfeeding techniques among nursing mothers in sub-Sahara Africa (SSA). This study assessed breastfeeding knowledge, attitude and techniques of postures, positioning, hold practice and latch-on among Nigerian mothers. Exclusive breastfeeding is encouraged and recommended to all mothers worldwide with efforts being made both in the private and public sector as a way of achieving the Millennium Development Goals (MDGs) on improving maternal health. These efforts are also directed at reducing infant morbidity and mortality related to mixed-feeding as breast milk is very vital for the newly born babies. According to UNICEF (2010), exclusive breastfeeding is giving baby breast milk only and nothing else, not even sips of water except for medicines prescribed by the doctor or nurse for the first six months of life. According to World Health Organization (2006), in 1991, United Nations International Children’s Fund (UNICEF) and World Health Organization (WHO) began an international campaign called Baby Friendly Hospital Initiative. This initiative was meant to promote, protect and support breastfeeding. Most hospitals in Nigeria have Baby Friendly Initiative. One of the ten steps for Baby Friendly Initiative states that there should be no advertising of formula products used for babies under six months. In line with this agreement, Nigeria prohibits the advertisement of such products on all media in an effort to promote exclusive breastfeeding. Consequently, this necessited the Innocent Declaration commendation of 1990 by WHO/UNICEF Policy makers that all infants should be fed exclusively on breast milk from birth to 6 months of age (Galtry, 2003). However, this clarion call is to be answered by all mothers, in our contemporary society women are actively involved in paid job which has strict laws and codes of conduct which may not enable them have adequate time, to practice exclusive breastfeeding. In this study the researcher sets out to unravel those socio-economic determinates of exclusive breastfeeding among working mother's in KARU in order to give recommendations that will help improve the rate of exclusive breastfeeding. Breastfeeding has been accepted as the most vital intervention for reducing infant mortality and ensuring optimal growth and development of children (Gupta & Arora, 2007). Breastfeeding is the ideal method suited for the physiological and psychological needs of an infant (Subbiah, 2003). It is estimated that sub-optimal breastfeeding, especially non-exclusive breastfeeding in the first 6 months of life, results in 1.4 million deaths and 10% of the disease burden in children younger than 5 years of age (WHO, 2009). Exclusive breastfeeding (EBF) for the first 6 months of life improves the growth, health and survival status of newborns (WHO, 2003) and is one of the most natural and best forms of preventive medicine (WHO, 2001). EBF plays a pivotal role in determining the optimal health and development of infants, and is associated with a decreased risk for many early life diseases and conditions, including otitis media, respiratory tract infection, diarrhoea and early childhood obesity (Ip et al., 2007). It has been estimated that EBF reduces infant mortality rates by up to 13% in low-income countries (Jones et al., 2003). A large cohort study undertaken in rural Ghana concluded that 22% of neonatal deaths could be prevented if all infants were put to breast within the first hour of birth (Edmund et al., 2006). Reviews of studies from developing countries show that infants who are not breastfed are 6 to 10 times more likely to die in the first months of life than infants who are breastfed (WHO, 2000; Bahl et al., 2005). Some researchers have proposed that lack of suitable facilities outside of the home, inconvenience, conflicts at work, family pressure and ignorance adversely affect the willingness of women to practise EBF (Ogbonna et al., 2000; Forbes et al., 2003). The need to return to work has also been implicated as a factor interfering with EBF (Mahgoub et al., 2002). The objective of the present study is to investigate the attitude of working mothers to exclusive breastfeeding (EBF) in Karu L.G.A., Nasarawa State, Nigeria. 1.2 STATEMENT OF THE PROBLEM There has been an increase in infant mortality due to diarrhoeal diseases and illnesses, associated with malnutrition since the introduction of bottle feeding in our society. The economic burden on families and the community has substantially increased with bottle feeding and use of infant formulas. 1.3 OBJECTIVES OF THE STUDY 1. To assess the knowledge of working class mothers regarding exclusive breastfeeding. 2. To verify their attitudes and practices of exclusive breastfeeding. 3. To determine the factors that influence their attitudes and practices of exclusive breastfeeding. 4. To investigate factors that affect or influence working class mothers towards exclusive breastfeeding and establish the nutritional status of non - exclusively breastfed infants in Karu L.G.A. 1.4 RESEARCH QUESTIONS The purpose of this study was to investigate types of primigravidas´ knowledge regarding exclusive breastfeeding, to explore attitudes they have towards and identify the possible challenges they experience during exclusive breastfeeding period. The goal of the study was to provide knowledge for mothers to acquire the authentic depiction regarding exclusive breastfeeding by new mothers. The research questions included: 1. What kind of knowledge primigravidas had concerning exclusive breastfeeding? 2. What were the attitudes of working class mothers towards exclusive breastfeeding? 3. What were the possible challenges that primigravidas experience during exclusive breastfeeding period? 4. What are the factors that hinder exclusive breastfeeding practice? 5. What is the attitude of working class mothers towards exclusive breastfeeding? 6. What is the nutritional status of non - exclusively breastfed infants ? 7. What is the influence of mothers working on exclusive breastfeeding? 1.5 Specific objectives i) To identify factors that hinder exclusive breastfeeding practice. ii) To establish the mothers‟ level of knowledge of exclusive breastfeeding. iii) To assess the nutritional status of non – exclusively breastfed infants. iv) To determine the relationship between mothers socio-demographic characteristics and exclusive breastfeeding practice. 1.6 Null hypothesis There are no factors that hinder exclusive breastfeeding practice. 1.7 Significance of the study There is need for greater efforts to promote and support the healthy practice of exclusive breastfeeding. The planning of public health interventions to promote longer and more exclusive breastfeeding practice requires an understanding of the factors that hinder the practice. More efforts are needed to promote exclusive breastfeeding among mothers in order to realize international feeding practices of the infants. Health education on breastfeeding should be improved in order to eliminate barriers to exclusive breastfeeding. The findings can be used in designing appropriate and effective breastfeeding intervention programmes aimed at improving infant and young children feeding practices. These findings will provide insights for exclusive breastfeeding promotion programmes of mothers in Eldoret, Kenya. The findings will contribute some extra knowledge in the study area and therefore serve as a basis for implementing child health policies. The research findings will form a basis for other researches on breastfeeding such as the plight of breastfeeding employed mothers. 1.8 Limitations The study was not inclusive of mothers who do not attend child welfare clinics. The study did not include HIV positive infants Therefore results may not be generalized to the entire population of mothers with infants aged 0-6 months. Data on infant feeds and diseases were reported during the survey and were not based on observation. Language was another limitation. Most mothers could not understand English and therefore questions were asked verbally in Hausa. The translation may to some extent have altered the meaning of the question. CHAPTER TWO 2.0 LITERATURE REVIEW 2.1 INTRODUCTION Breastfeeding is the first step in life which ensures that infants and young children get a healthy and nutritious start in life. It is one of the few consistent sources of energy-dense food, even into the second year of life. Exclusive Breastfeeding for 6 months is the optimal way of feeding infants. Therefore, infants should receive complementary foods with continued breastfeeding up to 2 years or beyond 5 years. Exclusive breastfeeding refers to the feeding of the infant with only breast milk, without any additional food or drink, not even water. Breastfeeding exclusively for 6 months is not a common practice in developed countries and appears to be rarer still in developing countries. 2.2 The historical background of breastfeeding Breastfeeding has been practiced since mammals existed on earth. Breastfeeding was rarely described even by those few ancient writers interested in infant health. The ancient Greek and Roman medical writings from Hippocrates, Soranus and Galen included infant health and feeding to some extent in their broader treatises on health (Ted, 1998). As far as the duration of breastfeeding accepted in ancient civilizations was concerned, it was said that “Plotinus at the age of eight used to run from his tutor to his nurse and clamour for the breast” (Wickes, 1953). Ploss et al. (1935), estimated an average breastfeeding duration of 3 – 4 years among “primitive” peoples. Hawaiians were said to breastfeed for five years and Eskimos for about 7 years reaching a maximum in King William Land of up to 15 years. Ford, (1945), noted that breastfeeding continued for 3 years or longer in 15 of 45 “primitive” cultures, for 2 years in 16 of them, for 18 months in 13 of them and for 6 months in one culture. Wickes, (1953) located one source from the late 1400s suggesting that it was by then normal to breastfeed for only about one year in Germany. In Italy, it was noted that women gave up breastfeeding by the third month and stopped breastfeeding by the 13th month. Before the last few hundred years, alternatives to breastfeeding were rare. Attempts in the 15th Century in Europe to use cow’s or goat’s milk were not very positive. In the18th century, flour or cereal mixed with broth were introduced as substitutes for breastfeeding but this did not have a favorable outcome either. True commercial infant formulas appeared on the market in the mid 19th Century but their use did not become widespread until after World War II (Ted, 1998). Before the 1900s, if a mother did not breastfeed, a substitute “wet nurse” was hired to do it (Gordon et al., 1994). Traditional patterns of both breastfeeding and other care for nutrition have been subjected to erosion. Wet nursing by grandmothers, a very valuable custom, rarely received reinforcement from breastfeeding programmes and hence has been lost (Ebrahim,1991). During the early 1900s, the technology of formulas and feeding improved. From the 1920s, and especially in the 1940s when women worked in armament factories during WW II, more and more babies were fed formula. Throughout the 1950s and early 1960s, interest in breastfeeding further waned. In the 1970s, breastfeeding enjoyed a resurgence, which has since leveled off (Gordon et al., 1994). In 1981 and 1987, the La Leche League International (LLLI) board of directors voted to support the WHO / UNICEF International Code of Marketing of Breast milk Substitutes. In February 1988, the board directed LLLI to cooperate and network with other key breastfeeding organizations around the world and to lend strong US support to struggling countries. In October 1988, the board voted to support the efforts of the American Academy of Paediatrics for their policy opposing direct advertising of infant formula to the public. This was recognized as a positive step towards increasing the incidence and duration of breastfeeding in the US. The move was to lend support to breastfeeding worldwide. On July 21, 1991 a historic meeting was held in the USA to discuss the marketing of artificial infant feeding in the US. At this meeting a consortium drafted the “Declaration for the Protection, Promotion and Support of Breastfeeding” (Janet et al, 2008). Breastfeeding was the normal way of feeding infants in all traditional societies. In a world - wide study of 45 different cultural and ethnic groups in the 1940s, it was found that on average the infant breastfed for 1.5 – 2 years. In some communities it continued for as long as 6 years (Ebrahim, 1991). A multi – nation study sponsored by WHO, in 1981 found three main patterns of breastfeeding; in the first pattern, breastfeeding was rarely continued beyond 6 months and there was a tendency to terminate breastfeeding even sooner than that. On the other extreme, breastfeeding was prolonged and almost universal with about 50% of the mothers continuing to breastfeed at the age of 18 months. A third group of mothers exhibited a pattern which fell midway between the two extremes (Ebrahim, 1991). 2.3 Effects of beliefs and attitudes on exclusive breastfeeding In many places, people regard breastfeeding as normal, but they have other ideas that can interfere with it. Sometimes people approve of breastfeeding but believe that it is not enough by itself and that babies need something else as well. Many mothers decide to feed their babies artificially-either partially or completely because they believe that they do not have enough breast milk. According to Lousekuhn et al. (2001), and Lakati (2002), a mother’s perception of insufficient breast milk production is a barrier to exclusive breastfeeding as found in South Africa. Some mothers give babies bottle feeds as well to make them fatter, because they believe that it is healthier (Morrow,1996). For Asian families, formula feeding is seen as a way to ensure that babies will grow to be physically larger and to have harder bones (Morrow, 1996). Some women do not want to stay with the baby all the time to breastfeed, they want to be free to go out with friends or go to work. They believe that breastfeeding will not suit their ways of life. The findings of a study among Hong Kong women showed that women tended to consider breastfeeding as socially limiting and thought that women should not be tied to the baby and family (Kong et al., 2004). Colostrum has traditionally been viewed as “bad milk” (Ergenekon et al., 2006). The colostrum is discarded because of the general belief that it is „heavy‟ or „not good for the child‟. Turkish migrant mothers believe that colostrum, “Mawu / fro” causes stomache and infants dislike this milk. Mothers squeeze their breasts to get rid of this milk (Ergenekon et al., 2006). In many developing countries, mothers do not give that first milk because they fear it to be “pus” or “poison” (Adegbo, 1997). 2.3.1 The benefit of breastfeeding to the baby Breast milk is the natural food for infants during the first months of life. It contains all the nutrients a baby needs for the first six months of life. Breast milk contains antibodies to protect the baby against infections, there is less gastroenteritis, fewer respiratory and ear infections among breastfed babies (Penny et al., 2005). Infants fed on breast milk have less risk of atopic eczema, asthma, lower rates of obesity, diabetes and coronary heart diseases in the later life. The suckling required in breastfeeding is more vigorous and encourages the healthy development of jaws and gums (Penny et al., 2005). Breastfeeding is important for physical health and neurological development. There is a possible decrease in the risk of cot death and a possible increase in Intelligence Quotient. Some studies suggest that long- term intelligence or cognitive scores increase with the mother`s choice to breastfeed and with the duration of breastfeeding (Pollack, 1994). Breastfeeding may be particularly important in neurological development when some impairement is present at birth (Lanting et al., 1994). The hormones released during breastfeeding strengthen the maternal bond. 2.3.2 The benefit of breastfeeding to the mother Breastfeeding on demand helps protect against another pregnancy (Paget et al., 2004). Breast suckling prevents ovulation through the hormone prolactin. Prolactin has an inhibiting influence on the synthesis of ovarian steroids. The longer and more completely the infant suckles, the more delay in the return of the ovulation cycle and thus the mother‟s fertility. Breastfeeding helps the uterus to return to its original size much more quickly. Breastfeeding soon after giving birth increases the mother’s oxytocin levels making her uterus contract more quickly and reducing bleeding (Ford et al., 1990). Women who breastfeed are less likely to suffer from uterine disorders, ovarian and breast cancer (Penny et al., 2005). According to Mitch et al., (2006) breastfeeding allows for quicker weight loss after pregnancy. The fat reserves set aside during pregnancy are used to manufacture milk (David et al., 2001). Breastfeeding uses an average of 500 calories a day, thus, it helps a mother to lose weight after giving birth (Saadeh, 1996). 2.4 Factors influencing mothers’ exclusive breastfeeding 2.4.1 Level of knowledge on breastfeeding Having adequate information about breastfeeding and failing to experience problems during breastfeeding period are found to influence mothers to breastfeed their infants. One of the elements to empower a woman to breastfeed is that she has sufficient knowledge to make decisions (Shelton, 1994). Breastfeeding choice and success are usually associated with higher knowledge on breastfeeding (Wallace, 1992). 2.4.2 HIV status The fear of transmitting HIV through breast milk is a factor that contributes to the decline in breastfeeding. HIV- positive mothers could be targeted by the distributors of infant food products. A four-country study on breastfeeding in selected African countries concluded that there has been a reduction on support of breastfeeding as a result of fears and misinterpretation of the UNAIDS/WHO/UNICEF guidance related to HIV and breastfeeding (Miriam et al., 2005). A recent study in Zimbabwe indicates that postnatal transmission of HIV can be halved from 14% to 7% by exclusive breastfeeding in the first three months of life (Jolly, 2006). The risk of HIV infection in breastfed babies is smaller than the risk of non breastfed babies getting other infectious diseases in present conditions in many developing countries (Paget et al., 2004). If a HIV positive mother decides to breastfeed, some evidence exists in favor of exclusive breastfeeding (Steichen et al., 2002). It remains unclear why exclusive breastfeeding is better than mixed feeding. Possible explanations include a reduction in dietary antigens and pathogens which are assumed to provoke an inflammatory response or alter infant‟s gut integrity; the promotion of beneficial intestinal microflora by breast milk which may increase resistance to infection (Coutsoudis et al., 2001). 2.4.3 Age The literature on the determinants of breastfeeding has consistently identified lower maternal age as predictors of lower breastfeeding rates (Scott et al., 1999). A young mother with her first child may find it difficult to believe that she can breastfeed successfully. Breastfeeding fails easily in a young school girl who has a baby that she really did not want (King et al., 1983). The young mother feels shy to breastfeed and this impairs milk secretion. The young women to a large extend perceive their breasts in terms of their attractiveness rather than their function. Several mothers with a child at the end of a large family give up breastfeeding rather easily, although they had no difficulties with earlier children (King et al., 1983). Age above 25 years has been repeatedly associated with a longer duration of breastfeeding (Scott et al., 2001). It is probable that older women know more about the benefits of breastfeeding and have more realistic outcome expectations (Lawson et al., 1995). If a young woman is interested in breastfeeding, she should talk to women who have done it successfully. Experienced mothers can be an enormous help to the first time mother (Freed, 1993). 2.4.4 Marital status Single mothers have great difficulty supporting themselves and caring for the baby especially if they are young. Single mothers have less family support. Without this support, activities outside the home such as having to work might prevent EBF. It is often best if the mother and the baby can stay together and be supported as a family. They can breastfeed at least partially (Ebrahim, 1991). 2.6.5 Education A woman’s educational and social class affects her motivation to breastfeed but the way it affects is different in different parts of the world. In many industrialized countries in the west, breastfeeding is more common among the educated and upper class women. On the other hand, in third world countries the educated and upper class women are more likely to feed their infants artificially (King et al., 1993). Generally educated women tend to breastfeed less and are likely to introduce supplementary feeding earlier than those with little or no education. This is attributed to the fact that a better educated woman is more likely to work away from home which makes breastfeeding difficult (Luan, 2003). The KDHS (2003), found an inverse relationship between education and mean duration of breastfeeding. 2.4.6 Employment A woman may choose not to breastfeed because she plans to go back to work outside home soon after the baby is born and feels it is too difficult to work and also breastfeed. Other women find it hard to maintain their milk supply when separated from their babies and may be forced to stop breastfeeding (Fisher et al., 1990). Maternal employment outside the home is often cited as a major factor in short- term breastfeeding patterns seen throughout the world (Perry, 2003). 2.4.7 Cultural factors The decision to breastfeed is very often influenced more by socio-cultural factors than by health consideration (Henderson et al., 2000). Ergen ekon et al., (2006) noted that cultural beliefs have a significant influence on breastfeeding practices. When perceived primarily as sex symbols, the breasts must be decently hidden which makes breastfeeding in public places difficult (Fisher et al., 1990). Breastfeeding in a public place or in the presence of friends is an activity that is extremely sensitive to cultural norms. Findings of the study done among women in Hong Kong showed that majority of the women agreed that it was unacceptable to breastfeed in front of others except the husband and the health care workers (Kong et al., 2004). Society has stressed modesty and frowned on baring breasts in public even in so good a cause as nourishing babies (Freed, 1993). In most African countries, breastfeeding is still considered an important part of the traditional culture and is actively supported and promoted by community members (Walker et al., 2000). 2.4.8 Husband / Family support The role of the husband as a supporter of breastfeeding is mentioned in the lay literature. Particularly when he has a positive mind - set relating to breastfeeding, it is thought that he can play an important role (Litman et al., 1994). The presence of the husband at delivery tends to make him more supportive of breastfeeding (King et al., 1993). Women who have breastfed have often had problems because of lack of experience and support around them (Fisher et al., 1990). In some places, the husband thinks that breastfeeding is normal and important and most mothers breastfeed successfully. In other places, the husband does not understand the importance of breastfeeding or may disapprove breastfeeding in public places; then it is more difficult for women to breastfeed successfully (King et al., 1993). A man’s positive or negative attitude towards breastfeeding can easily influence a woman’s breastfeeding behaviour. Men may disapprove of breastfeeding if they believe it will interfere with sexual activity, will make women lose their breast shape or cause women to expose their breasts in public (Bryant et al., 1992 and Beutley et al., 1999). According to Kessler et al., 1995, the child’s father may be supportive of breastfeeding if he realizes that the economic benefits of the mother’s milk will free him from the responsibility of obtaining infant foods. Other husbands, especially those who understand the nutritional value of breastfeeding, like the health professionals may not buy their babies infant formula even though they could afford. Several studies have demonstrated that the nursing mother needs emotional support especially during the early days of lactation, provided by the people she trusts (Ebrahim, 1991). The attitude of husbands, relatives, friends and the community, all affect women’s decisions about breastfeeding positively or negatively (King et al., 1993). Hogan (2001), noted that lack of family support is a barrier to exclusive breastfeeding. 2.4.9 Religion The Islamic holy book, the Quran, recommends that mothers breastfeed their children for two years if possible and states that “every infant has the right to be breastfed. That if a mother is unable to breastfeed, she and the husband can decide together to have a wet nurse feed the child” (Jessica, 2007). Islam has codified the relationship between the wet nurse and the infants she nurses and also between the infants when they grow up, so that milk siblings are considered as blood siblings and cannot marry (Jessica, 2008). The Shulchan Aruch, based on the Talmud, allows breastfeeding until age two in all cases and up to age 4 (or 5 if the child is sick as long as the child has not ceased nursing for 72 hours). The reason for this is that adults are forbidden to breastfeed although they may drink mother’s milk indirectly (Ari, 2006). Islam contradicts breastfeeding. The Islamic society represses and suppresses women who are generally believed to be inferior to men. In most Islamic nations, women have to be covered from head to toe (Ari, 2006). This is a cultural barrier that hinders breastfeeding. Other religions support breastfeeding. For example, the La Leche League International was founded by Catholic mothers in support of breastfeeding. 2.5 ADVANTAGES OF BREASTFEEDING FOR THE INFANT 1. Provision of essential and adequate nutrients to the infant at the right temperature and with minimum stress to the absorptive capacities of the baby. 2. Reduces the sickness rate of children e.g. gastroenteritis and respiratory infections. 3. Reduces the incidence of allergic disorders. 4. Provides bonding between the mother and child, hence, improving the psychosocial development of the child. 5. It is hygienic, safe and always available to the infant. FOR THE MOTHER 1. Provides satisfaction to the mother. 2. Protects against breast and ovarian cancers. 3. Aids faster involution of the uterus with reduction in post partum morbidity. 4. Protects against early pregnancy post delivery. THE TEN STEPS TO SUCESSFUL BREASTFEEDING Every facility providing material service about care for newborn infants should: 1 Have a written breastfeeding policy that is routinely communicated to all health care staff. 2 Train all healthcare staff in skills necessary to implement this policy. 3 Inform all pregnant women about the benefits and management of breastfeeding. 4 Help mothers initiate breastfeeding within a half hour of birth. 5 Show mothers how to breastfeed and how to maintain lactation even if they should be separated from their infants. 6 Give newborn infants no food or drink other than breast milk unless medically indicated. 7 Practice rooming-in: allow mothers and infants to remain together--24 hours a day. 8 Encourage breastfeeding on demand. 9 Give no artificial teats or pacifiers (also called dummies or soothers) to breastfeeding infants. 10 Foster the establishment of breastfeeding support groups and refer mothers to them on discharge from the hospital or clinic. 2.5.1 ATTITUDE TOWARDS EXCLUSIVE BREASTFEEDING According to a research carried out in Karu Local government, (Nassarawa, Nigeria), there was a general lack of awareness of some major recommended practices in the hospitals that will promote and sustain breastfeeding. There is therefore, the need for policy changes and BFHI training for the staff of these health facilities to respond to the concern and growing need for proper infant/ young child feeding. From the study, only 20.8% of the health workers were aware of the need to initiate breastfeeding, within 30 minutes of birth. Also, a low proportion (36.8%) was aware of the existence and duties of breastfeeding support groups. These 2 practices in the hospital have been shown to enhance initiation and maintenance of breastfeeding. From a study done on working class mothers in Karu metropolis, Nigeria, 91% of the subjects knew that breast milk was ideal for their baby, while 8.5% felt that infant formula was best and 0.5% considered others namely pap as ideal. These indicate a high level of awareness among mothers, of exclusive breastfeeding and the importance of breastfeeding. The question now is; do they put what they know or have learnt into practice? From the study on working class mothers in Enugu, despite the high level of awareness of breastfeeding, only 15.5% of the mothers actually practiced exclusive breastfeeding. The research in KARU local government, revealed that only 5.2% of the healthy workers interviewed were able to demonstrate correct positioning of the baby for breastfeeding and only 19.2% believed that babies less than 6 months of age should not be given water. From the foregoing, it is evident that despite the high level of awareness of exclusive breastfeeding and breastfeeding in general, very few put it into practice. It becomes necessary to try to find out why this is so. 2.6 ATTITUDES OF WORKING CLASS MOTHER TOWARDS EXCLUSIVE BREASTFEEDING Most of the working class women in Karu who don’t practice exclusive breastfeeding put the blame on constraints from work while others blamed cultural practices. Tradition and career were the strongest factors affecting the attitude of the mothers in KARU towards exclusive breastfeeding. Women with higher education and higher income were less likely to breastfeed. Similarly, employed mothers, mothers with lower numbers of children and those who delivered by caesarean section were less likely to fully breastfeed. It is also important to note that independent of maternal socioeconomic, demographic and biomedical characteristics, maternal pregnancy overweight and obesity have been identified as factors that reduce the duration of breastfeeding. It is therefore the intention of this research to assess the knowledge, attitudes and practices of exclusive breastfeeding among nursing mothers in KARU Urban and to find out the factors that influence these. Research showed that a large number of mothers are not practicing Exclusive breastfeeding as a result of poor knowledge which result in poor attitude towards it. For instance, Chetley (2003) identified negative perception of breastfeeding like insufficient milk, fear of weight gain, breast sagging, pain, sleep deprivation, exhaustion or maternal employment as the problems highlighted by poor attitude mothers who are not positive towards exclusive breastfeeding. In the same vain inadequate knowledge or inappropriate practice of breastfeeding were identified as those factors which can lead to undesirable consequences which also affect mother's attitude. Nevertheless, Mennela (2001) realized from his study that women who continued breastfeeding exclusively were more determined to success and overcome any barrier, relying mostly on family support and proper time management 2.7.1 BENEFITS OF EXCLUSIVE BREASTFEEDING TO THE CHILDREN IN NIGERIA The advantages of exclusive breastfeeding are widely documented Dana, price, Simon & Schuster 1987). 2.7.2 Provision or Colostrums During the early days after delivery breastfeeding provides the baby with the benefits of colostrums. Colostrums are the pre-milk substance secreted by the breasts, until milk is produced usually about the second or third postpartum day. Colostrums is rich in all baby's essential need like vitamins, nutrients, fluids to help clear excess mucus from the or her mouth and throat, special laxative properties that help clear the baby's intestinal tract of meconium baby's first stool) and substances that prevent infections and allergies Jones, 1993), Breast milk provide all the nutrient and vitamins the baby needs at least for the four to six months after birth. The baby receives everything she needs for needs for optional healthy development from the mother's milk with no supplement (Jones, 1995). 2.7.2. Prevention of Diseases Breast milk contains immunologic factors and antibodies that help prevent a host of diseases. Antibodies are immune substances in blood and body fluids effective in fighting infections and other foreign substances in the blood. Breast milk contains antibodies which protect the infant from any infections and diseases, particularly infection of the intestinal tract since also there is no exposure to infected water, contaminated bottles amongst other containments the breastfed baby is far less susceptible to diarrhea, which in infants, is a potentially serious condition (Jones, 1993), Measles, ear infection, and respiratory illnesses (Unicef 2001). Those who are not breastfed fall sick more often and visit hospitals and clinics more often and have 50% lower survival rate than the breastfed children. 2.7.3. Development of the Teeth and Jaw, Reduction of In families Obesity And Meeting of Emotional and Psychological Needs The body teeth and jaw develop best when the mother breastfeeds, sucking at the breast appears to lower the incidence of fault closure of the teeth malocclusion (Jones, 1993), Breastfeeding markedly reduced the chance of infants, obesity. Obesity in infantile can predispose the child to obesity later in life (Jones, 1993). Breastfeeding fills many of the baby emotional and psychological as well as psychological needs. Breastfeeding offers a special closeness that helps develop the material child relationship during the early months of life. At the same time it gives the baby the emotional and physical pleasure (Lawrence 1995). 2.7.4. Reduction in Infant Mortality and Neurodevelopment and Child Growth Studies suggest decreased rates of sudden infant death syndrome in the first year of life and reduction in incidence of insulin dependent (typed 1 and non insulin dependent (type 2) diabetes mellitus, lymphoma and leukemia disease, overweight and obesity, hypercholesterolemia and asthma in older children and adults who were not breastfed (Kramarm, et, al, 2001:414). It has been proven that and child growth breastfeeding has been associated with slightly enhance performance on tests of cognitive development (Jones, 1993). Also, child that is breastfed will have better weight and growth gain and development. 2.8. Attitude Solutions with Exclusive Breastfeeding Although exclusive breastfeeding is an important behavior that has seen identified as related to improved health of mothers, infants and children as well as lower health care cost. Exclusive breastfeeding based on available evidence, achievements of these goals are still far from the desired progress. Exclusive breastfeeding practices including initiation and duration are influenced by multiple inter woven factors which include health, psychosocial, cultural, political and economic factors. Among these fetors, decision regarding exclusive breastfeeding in low-income countries are influenced by education, employment place of delivery, family pressure, cultural values, and spouse support within the home. To further explain, much research which looks at exclusive breastfeeding behavior shows that there are complex relationships to it which involves not only incentive, but disincentives as well. Often the disincentives outweigh the advantages for many women. These disincentives form any barriers to compliance with the breastfeeding recommendations. These common factors which affect exclusive breastfeeding practice are the mother returning to work outside of the home, the support of the other within the home and mother psychological I health (Chudasama, Patal and Kavishwar, 2009). Gundelman et al, (2009) indentified lacking job flexibility and psychosocial stress as the barriers to exclusive breastfeeding practice by working; mothers. Further explanation puts in that one of the problems continually encountered by working mothers which tends to reduce the rate of exclusive breastfeeding is sex-specific, and therefore, cannot be viewed as gender neutral in child bearing. The act of breastfeeding becomes even more difficult because many do not consider exclusive breastfeeding to be critical for baby survival. Thus specific legislation on breastfeeding of the right to pump milk, lactation at work, extra package to boost breastfeeding working mothers still remain a mirage. CHAPTER THREE RESEARCH METHODOLOGY 3.1 Research design Descriptive survey method was used to observe, describe and document aspects of the attitude of working class mothers towards exclusive breastfeeding in Karu L.G.A. Nassrawa state of infants. This design was chosen because the study was concerned with specific prediction and describing characteristics of a particular group (mothers and infants). The design was preferred as the topic was a social survey under social and behavioral sciences (Role, 2007). 3.2 Location of study The study was carried out within Karu L.G.A. in Nasarawa. The Karu Urban Area is an urban area in central Nigeria. The urban area is majorly located in the Nigerian state of Nasarawa, but with some parts stretching into the boundaries of the Federal Capital Territory (FCT). It consists of towns that developed as a result of urban sprawl from Abuja. From west to east, the urban area includes towns like Kurunduma, New Nyanya, Mararaba, New Karu, Ado, Masaka and newer, fast-growing towns such as One Man Village (which contains over 1 million people) and Gidan Zakara. Since the beginning of the 20th century, these districts have grown together into a large urban area and a major commercial centre of central Nigeria 3.3 Target population All mothers and infants who attended the MCH Postnatal clinics which were From west to east, the urban area includes towns like Kurunduma, New Nyanya, Mararaba, New Karu, Ado, Masaka and newer, fast-growing towns such as One Man Village (which contains over 1 million people) and Gidan Zakara 3.4 Population of Study It has an area of 40,000 hectares (400 km²) and a population of some 2 million. It is one of the fastest growing urban areas in the world, with a growth rate of 40 percent recorded annually. Mothers of infants aged 0-6 months drawn from the target population. 3.5 Inclusion criteria Mothers of infants aged 0-6 months who were willing to participate in the study. 3.6 Exclusion criteria Mothers of children aged 0-6 months not willing to participate. Mothers of children aged 0-6 months who were unwell. 3.7 Sampling techniques Each of the five health centers was visited on different days for 4 consecutive weeks. Each visit lasted 4 hours. This is because each clinic had 2 different specific MCH clinic days which operated from 8 am to 12 noon. Simple random sampling was used. Papers with two written choices yes and no were placed in a container. On each visit, mothers of children aged 0-6 months attending MCH clinics willing to participate, picked the papers at random. The subjects who picked the yes response were included in the sample. On each day, the total number of mothers and infants was recorded. Once the sample size of 296 mothers and infants was achieved, the visits ended. 3.8 Sample size From the Municipality report of June 2007, out of the 2,523 clients, 1,337 mothers attended the MCH clinics. Based on this, the desired sample size was calculated using the formula n=Z2pq / d2 ( Fisher et al., 1998), Where N is the desired sample size if the target population is greater than 10,000 Z is the standard normal deviate at the required confidence level P is the proportion in the target population estimated to have the characteristic q = 1-p d is the level of statistical significance Hence p = 1337/2523 = 0.53, n = 1.962(0.53) (0.47)/0.052 Z = 1.96 = 382 d = 0.05 q = 1-p =1-0.53 = 0.47 Since the target population was less than 10,000, that is, 1,337, a final sample estimate was calculated using the formula: nf = n /1+n / N = 382 / (1+382) /1337 = 296 Therefore the sample size was 296. 3.9 Data collection instruments Research instruments used were questionnaire and personal interview schedules. Closed ended questions and structured interview schedules were constructed. A six-part questionnaire was developed on the basis of literature review. Part A - Socio- demographic characteristics of the mother Part B – Nutritional status of the baby Part C - Employment Part D – Knowledge level Part E – Personal factors Part F – Social support Anthropometric Method that involved height and weight measurements was used to assess the nutritional status of infants. For reliability, the questionnaire was initially pretested to 20 mothers who were not among the final 296 respondents. 3.10 Data collection techniques The questionnaire and the structured, face - to - face interview schedule were researcher-administered. Personal interviews were done using a structured questionnaire on participants who could not read. Mothers were asked to state how much they knew about EBF. Established true facts about breastfeeding were used to rate maternal knowledge on breastfeeding. Mothers were asked to respond to established true facts testing knowledge (under part E of the questionnaire), as strongly agree, agree or disagree. Anthropometric Measurements Infant weight was taken using a 25 kg Salter Scale graduated in 100gm. The infant‟s clothes were removed except the vest, before being placed on the weighing pan. Before each series of weight measurement, the scale was adjusted to read zero. Weight was read twice and recorded to the nearest 100gm, (in kg). Infant height was taken by use of a calibrated measuring board from the forehead to the toe. The infant was placed on the hospital bed lying flat straight and facing up. Measurements were taken twice; one immediately after another and recorded to the nearest 0.1 cm. The average reading was used to ensure accuracy. Infant’s age (in months) was determined using the child health card and also by asking the mother when the baby was born. All mothers who attended the MCH clinics had been issued with child heath cards. 3.11 Data analysis Data from the survey was statistically analyzed using the Statistical Package for Social Sciences (SPSS) (version 12.0). Inferential statistics and chi- square were performed to compare the effects of attitude of working class mothers towards exclusive breastfeeding. Since the study was about a relationship (dependency between exclusive breastfeeding practice and working class and other factors) chi-square statistic (χ 2) was used to establish whether relationships existed among the variables. Statistical significance was assumed for P – values, < or = 0.05. Basic descriptive analysis were done using frequency distributions. Qualitative data was sorted, categorized and conceptualized in a systematic way to uncover patterns of exclusive breastfeeding. Measures of central tendency were used to give expected summary statistics of variables studied. Descriptive statistics was used to describe a distribution of scores. Findings were presented by use of frequency distribution tables, charts and graphs. The Epi Info 2002 software package was used for the analysis of Quantitative data. First the raw measurement data (weight and height) were entered into the computer. Second, the programme combined the raw data on the variables (age, sex, length, weight) to compute nutritional status indices, that is, weight for age (underweight), an overall indicator of a population’s nutritional status, height for age (stunting) measure of linear growth and weight for height (wasting) an indicator of current nutritional status. Third, the programme transformed these data into Z-scores so that the prevalence of nutritional conditions such as underweight, wasting and stunting could be calculated. Children were classified as malnourished if their Z- scores were below -2 or - 3 standard deviation (SD) of the reference population based on the WHO Child Growth Standards (WHO, 2006). (Roberto F.A., 2007). Children with Z-score below <-2 SD to > -3 are considered moderately, < -3 Z- score, severely malnourished. A child below -2 SD from the median of the reference population in terms of weight for height is considered too thin for height (wasted), a condition reflecting acute / recent nutritional deficit. Below -3 SD is severe wasting which is closely linked to mortality risk. 3.12 Logistical and ethical considerations This included seeking legal authority from Medical Officer of Health, Karu L.G.A. and clearance from Open University Graduate School to carry out the study. A sample questionnaire was given to the MCH staff in order to clarify issues and obtain their co- operation. Respondents consent (signed) consent for study participation was sought through attaching a brief consent form with the questionnaire that addressed the nature of the study. Informed verbal consent was also sought. During the interviews, mothers were encouraged to talk freely. The respondents‟ information was treated confidentially. CHAPTER FOUR RESULTS AND DISCUSSION This chapter covers results and discussion starting with socio – demographic characteristics of the mothers. This is followed by factors that hinder exclusive breastfeeding practice, maternal understanding of exclusive breastfeeding, nutritional status of infants and the relationship between working class mothers and exclusive breastfeeding practice. 4.1 Socio – demographic characteristics of the mothers The sample size of the study population was 296 mothers. The variables of interest researched on were age, marital status, level of education and employment status. The mothers‟ ages ranged from I5 to 44 years. The highest percentage of the mothers (31%) were in the age group of 25- 29 while the least percentage (1.4%) were in the age group 40-44 years. The mean age of the mothers was 25 years. Twenty seven percent of the mothers had secondary education while 15% had tertiary education. Most of the mothers were engaged in some form of employment with only 39.5% having no employment. More than three quarters of the mothers (78%) were married while 22% were single. 4.2 Factors that hinder exclusive breast feeding practice The important factors that hindered EBF were mother’s insufficient breast milk production, mother’s inability to express breast milk, to improve infant’s health, mother’s return to work, mother socially tied down, inadequate knowledge about EBF and lack of health messages on EBF from both antenatal and post- natal clinics. Factor percentage Insufficient breast milk production 40 Inability to express breast milk 24 Lack of health messages from clinics 17 Mother returns to work 15 Breastfeeding as socially limiting 4 Total 100 Table 4.1 Factors hindering mothers from exclusive breastfeeding Many mothers decided to feed their babies artificially – either partially or completely because they believed that they did not have enough breast milk. On responses given under personal factors, 20.6% strongly agreed, 39.9% agreed and 39.5% disagreed that they did not have enough milk; χ2 = 11.290, df =2, P= 0.004. Most mothers reported that their breasts could not produce adequate milk because the baby cried a lot on breastfeeding alone. This could be attributed to mothers not feeding well. They opted to give other feeds to satisfy the baby. Breastfeeding women should eat a well balanced diet and drink enough liquids like juice, water, milk and soup to increase milk production. Breastfeeding at least every two to three hours helps to maintain milk production. For most women, eight breastfeeding or pumping sessions every 24 hours keeps their milk production high (UNICEF, 1999). Feeding a baby on demand (when a baby shows signs of hunger) helps to maintain milk production and ensures the baby’s needs for milk and comfort are met (WHO, 2003). This study’s finding is similar to the one done in New Zealand on factors associated with duration of breastfeeding. The common reason for stopping breastfeeding among mothers was perceived insufficient milk in the first months (Vogel et al., 1999). According to Lousekuhn et al., (2001) and Lakati, (2002), mother’s perception of insufficient breast milk production was a barrier to EBF as reported in South Africa. Similarly, in a study done in Nairobi, breast milk insufficiency was one of the main reasons cited for the cessation of EBF (Lakati et al., 2002). 4.2.2 Mothers’ inability to express breast milk When mothers were asked if they expressed breast milk to leave for feeding baby while they were away, 7.4% responded yes, 92.6% responded no; χ2 = 4.373, df = 2, P=0.021.This was a barrier to EBF. If a mother could not express breast milk, it meant the infant had to be fed on other drinks / foods besides breast milk. Reasons for not expressing breast milk included mother’s lack of skill on how to express, lack of equipment like a breast pump to express breast milk, fear of contamination due to lack of refrigerators to store and other mothers saw no major need of expressing the milk. Expressing breast milk requires a skill. A mother can express milk by hand or using a breast pump into a sterile plastic bottle. Keeping breast milk requires careful sanitation 32 and rapid chilling. Breast milk may be kept at room temperature for up to 10 hours, refrigerated up to 8 days and frozen up to 4 to 6 months (Pediatrics, 2005). Mothers should know that expressing breast milk can maintain a mother’s milk supply when she and her child are apart. Expressed breast milk can be fed to the baby using a cup and a spoon, by the care taker when the mother is away. This ensures EBF for the baby. However, to be successful, the mother must produce and store enough milk and the care giver must be comfortable in handling breast milk. With good pumping habits, it is possible to produce enough milk to feed the baby as long the mother wishes. Most mothers expressed their dissatisfaction with availability of health messages on breastfeeding during both antenatal and postnatal clinic visits. On availability of health messages on EBF during antenatal visits 14.2% strongly agreed, 35.8% agreed and 50% disagreed; χ2 = 3. 857, df = 2, P = 0.047. On its availability during postnatal visits 18.2% 33 strongly agreed, 11.8% agreed and 69.9% disagreed; χ2 = 4.253, df = 2, P = 0.038. On rare occasions did they receive any messages encouraging them to breastfeed. If mothers are not encouraged by the health personnel to breastfeed, then they take exclusive breastfeeding practice for granted. On establishing if they received sufficient information on breastfeeding to enable them decide to breastfeed, 42.2 % respondent yes, 57.8% respondent no; χ2 = 11.468, df = 1, P = 0.001 at significance level 0.05. There was a significant relationship between information received on breastfeeding and exclusive breastfeeding. This means lack of adequate information hinders the practice of EBF. Most mothers reported that they did not get adequate support through advice from health workers to exclusively breastfeed. 4.2.4 The baby needs more than breast milk All the mothers of the infants aged 0-6 months had the following responses on baby’s need for more than breast milk. Those who strongly agreed were 36.1%, 44.6% agreed and 19.3% disagreed that the baby needed more than breast milk; χ2 = 19.079, df = 2, P = 0.044. Mothers approved of breastfeeding but believed that it was not enough by itself and that babies needed something else as well. Among the reasons given why mothers decided to give other drinks / foods besides breast milk was that the baby cried even when breastfed. According to the mothers, this suggested the baby was not satisfied and therefore needed something else. Another important factor for not practicing EBF was the perception of water as being indispensable for the infant’s health. Participants of another study among African American Women perceived that giving infants water was essential and they believed that cereal and solid foods should be introduced much earlier (Underwood et al., 1997). However, in Nepal breast milk was considered to be pure and while the infant was drinking only breast milk, he or she, unlike adults was not yet polluted (Moffat, 2002). Findings of this study indicated that some mothers gave babies bottle feeds to make them fatter because they believed that it was healthier. Among the reasons for giving other drinks / foods besides breast milk was to make infants grow bigger. Fifty four point one percent strongly agreed, 35.1% agreed and 10.8 % disagreed that breastfed babies were healthier. The findings of this study are similar to those of Asian families. According to Morrow, (1996), for Asian families, formula feeding was seen as a way to 35 ensure that babies grew to be physically larger and had harder bones. A survey done in Cameroon indicated that more than 38 % of the mothers supplemented breast milk in the first month of the infant’s life. Mothers gave reasons to mix feed their babies as breast milk being an incomplete food that did not increase the infant’s weight (Kakute et al., 2005). 4.2.5 Breastfeeding as socially limiting The findings of a study among Hong Kong women showed that women tended to consider breastfeeding as socially limiting and thought that women should not be tied to the baby and family (Kong et al., 2004). However, according to this study, many women disagreed that breastfeeding tied them down socially; 4.1 % strongly agreed, 31.4% agreed and 64.5% disagreed; χ2 = 16.89, df = 2, P = 0.004. This was not a major hindrance. Mothers who breastfed did it with pride and confidence, without being embarrassed. Breastfeeding is a natural thing to do and should be allowed everywhere even in public. Mothers should not mind other people’s negative opinions about breastfeeding. Breastfeeding is not time consuming and therefore would not limit social activities. 4.3 Mothers` understanding of EBF Mothers were rated on their responses testing their understanding on recommended age of EBF. Most mothers agreed that they knew little about EBF. According to the mothers‟ understanding, EBF periods were as follows; 0-2 months (51 %), 2-4 months (16 %), 4-6 months (10 %), other ages (23 %), χ2 = 14.884, df = 3, P= 0.002. This showed clearly that most mothers did not know the recommended age of EBF. According to Shelton 1994, one of the elements to empower a woman to breastfeed was that she had sufficient knowledge to make decisions. The low rates of EBF in this study could be attributed to insufficient knowledge on breastfeeding, as breastfeeding choice and success are usually associated with higher knowledge on breastfeeding (Wallace, 1992). The importance of mothers‟ breastfeeding knowledge has been shown in other studies (Chezem et al., 2003). According to Barbara et al. (2007), study findings on factors 37 associated with the duration of exclusive breastfeeding showed a positive significant association between the duration of EBF and mothers breastfeeding knowledge, meaning that having knowledge on breastfeeding promotes the practice of exclusive breastfeeding. From a study done in an urban health centre of Grant Medical Foundation, Ruby Hall Clinic, in Pune India, 75% of the mothers interviewed had antenatal education regarding breastfeeding. In a study done in Tanzania (Hufman, 1984), women not having knowledge of exclusive breastfeeding were more likely to terminate exclusive breastfeeding early. This lack of adequate knowledge could hinder the initiation and sustainability of EBF. 4.4 Nutritional status of infants There were 142 female and 154 male infants. The mean age of all infants was 2.9 months. The mean age of EBF infants was 1.8 months. The mean weight for all infants was 6.18 kg while the mean weight for EBF infants was 5.87 kg. The mean height of all infants was 52.11 cm whereas the mean height for EBF infants was 49.39 cm. Table 4.3 Age of introduction of other drinks / foods Age (month) Percentage <1 3 1 30 2 36 3 9 4 14 5 5 6 2 others 1 Total 100 Table 4.4 Percentage of infants below 6 months exclusively breastfed 2003 Study findings Age (month) percentage percentage percentage <2 28.2 29.3 31 2-3 8.0 9.3 5.1 4-5 3.5 2.6 2.0 6-7 0.6 2.1 0.0 <6 2.6 12.7 15.5 Source KDHS 1998 and KDHS 2003 4.5 Relationship between mothers` marital status and exclusive breastfeeding There was a relationship between marital status and exclusive breastfeeding; χ2 = 1.417, df = 1, P = 0.039 at significance level 0.05. The findings in this study showed that few single mothers exclusively breastfed compared to the married mothers. The likely explanation to this could be that single mothers as heads of households might have less family support. Without this support, activities outside the home such as having to work might prevent EBF. Findings from a study done in Tanzania (Marina et al., 1999), indicated that early termination of exclusive breastfeeding was 88 % for the unmarried women and 42.3 % for the married, that is, married women were the least likely to end exclusive breastfeeding early. A shorter intended duration of breastfeeding was associated with unmarried status. According to Ebrahim (1991), single mothers had great difficulty supporting them and caring for the baby especially if they were young. That it was best if the mother and the baby could stay together and be supported as a family, they could at least breastfeed partially. Perez – Escamila et al., (1995) suggested that in Honduras, women living in a home with the child’s father, exclusively breastfed less than single mothers. Similarly, according to Dr. Lutter, Latin American Regional Advisor on nutrition, the presence of the child's father at home could also be negatively related to EBF because providing infant formula could be a father’s way of showing support towards child feeding matters (Lutter, 2000). This could be attributed to the father’s lack of knowledge of the nutritional value of breast milk. In most cases, it is only mothers who get breastfeeding education during MCH clinic visits. 4.5.1 Relationship between mothers` level of education and exclusive breastfeeding There was a relationship between education level and exclusive breastfeeding. χ2 = 5.735, df = 4, P = 0.041 at significance level 0.05. The level of education did influence EBF practice. Mothers who had completed secondary education exclusively breastfed less compared to mothers who had completed primary education. Therefore higher levels of education were associated with low levels of exclusive breastfeeding. This study disagrees with KDHS, 2003 which found an inverse relationship between education and mean duration of breastfeeding. Women with no education breastfed longer than those who had at least some secondary education. Similarly the KDHS, 1998 also showed that mothers with incomplete primary education had a median EBF duration of 0.6 months while those with above secondary education had 0.5 months. A study done in Tanzania (Bureau of Statistics, Tanzania, 1993), showed that 44.7% women with primary education, 45.9% with secondary education and 54.3% illiterate women terminated EBF early. In Ethiopia, it was noted that mothers who were literate were seen to bottle feed more than their illiterate counterparts (Bekele et al., 1999). From a study done in India (Ashwin et al., 2007) 68% of the literate mothers exclusively breastfed as compared to 45% of the illiterate mothers who exclusively breastfed. Findings from a study done in Nigeria showed higher education of the mothers being associated with higher EBF rates, 81% (Ojofeitim et al., 2000). These women were more likely to have knowledge of EBF and therefore put it in practice. From a study done in Tanzania on factors related to early termination of breastfeeding (Huffman, 1984), maternal education was a factor that correlated significantly with improved feeding rates. From previous studies, a woman’s educational and social class affected her motivation to breastfeed but the way it affected differed in different parts of the world. According to King et al., (1993), in many industrialized countries in the west, breastfeeding was more common among the educated and upper class women. There could be reasons why more highly educated women continued to breastfeed longer than other women; they could be motivated to do so, they could be in a position to get hold of information on the management of breastfeeding problems, allowing them to continue breastfeeding through difficulty rather than weaning early (Lewisky, 2008). On the other hand, in third world countries, the educated and upper class women were more likely to feed their infants artificially (King et al., 1993). Generally educated women tended to breastfeed less and were more likely to introduce supplementary feeding earlier than those with little or no education. This could be attributed to the fact that a better educated woman was more likely to work away from home which made breastfeeding difficult (King et al., 1993). Other studies indicated that additional breastfeeding education did not significantly affect breastfeeding rate among the Women Infant and Children (WIC) Supplemental Nutrition Program Participants (Reifsnider et al., 1997). 4.5.2 Relationship between working class mother and exclusive breastfeeding There was a relationship between employment status and exclusive breastfeeding; χ2 = 2.629, df = 1, P = 0 .042 at significance level 0.05. Employed mothers stopped EBF earlier than mothers not employed. There is evidence from surveys of breastfeeding duration that employment status and associated employment practices may adversely impact on the duration of breastfeeding. The UK national infant feeding survey found that 19 % of those who stopped breastfeeding by 4 months attributed this to the need to return to work. This was the most often cited reason (39 %) for cessation by those who breastfed but ceased between 4 and 6 months, (Joanna, 2006). In a study done in India, 35% of the working mothers exclusively breastfed while 75% of the non- working mothers exclusively breastfed. A study done in Nairobi on the effect of work status on EBF showed a prevalence of 13.3 % at 3 months. Working mothers were able to continue breastfeeding although the EBF rates were low. Return to work was the main reason cited for the cessation of EBF (Lakati et al., 2002). Women who are unable to take an extended leave from work following the birth of their child are less likely to continue breastfeeding when they return to work. According to Perry (2003), maternal employment outside the home was often cited as a major factor to short – term breastfeeding patterns throughout the world. Mothers who were employed cited work away from home as a hindrance to exclusive breastfeeding. When mothers in this study were asked whether it was too difficult to work and also breastfeed, 84.5% respondent yes, 15.5% respondent no. Other women found it hard to maintain their milk supply when separated from their babies and were forced to stop breastfeeding. This research concurs with findings of other researchers who found out that maternal employment was a factor as in Hong Kong women’s decisions to wean early (Chan et al. 2000, Leung et al., 2002). The global recession has forced women back into the labour market immediately after giving birth. The result is that mothers are forced to return to full time jobs with a shorter breastfeeding time span, which in most cases may not be exclusive. In developed countries, many working mothers do not breastfeed their children due to work pressure (Scott et al., 1999). A mother may need to schedule for frequent pumping breaks and find a private place at work for pumping. These inconveniences may cause mothers to give up on breastfeeding and use infant formula instead. Employment of any form negatively affects EBF. A verbal interview with the nurses revealed that they did not practice EBF especially because they had to leave the baby and be on duty at night. Work outside the home can complicate plans to breastfeed. Some women can juggle both a job and breastfeeding, but others find it too cumbersome and decide to formula- feed instead (Freed, 1993). Perez et al. (1995), suggested that the working status did not show any significant relationship with the prevalence of EBF. Working women in Mexico might have started introducing foods / liquids long before resuming their jobs, so the relationship between a negative effect of having a job and EBF was not identified. Most studies find negative associations between employment and breastfeeding particularly the relationship between return to employment and shortened duration of breastfeeding although timing and intensity of return to employment are facets that complicate this negative association (Lindberg, 2000). 4.5.3 Relationship between form of work/employment and exclusive breastfeeding Of those employed, 31 (10.5 %) did office work, 115 (38.5 %) were in business, 33 (11.1 %) did farm work and 117 (39.2 %) did not specify the form of employment . There was also a relationship between form of employment and exclusive breastfeeding; χ2 = 3.542, df = 2, P = 0 .039 at significance level 0.05 Mothers doing office work exclusively breastfed less compared to mothers engaged in farm work or other forms of employment Poggensee et al. (2004), noted that employed and business women were more likely to stop breastfeeding earlier. A study on Analysis of Personal and Social factors influencing initiation and duration of breastfeeding in Queensland established that women with skilled jobs exclusively breastfed less than unskilled and non- working women (Papinczak et al., 2000). This could be attributed to the job conditions that may not allow caring for their babies. Such babies may have been left under the care of other persons who cannot breastfeed them. In studies done in Nigeria and Uganda, the results showed that not all types of mother’s work had a negative attitude on breastfeeding practices. In Nigeria, mother’s work had a negative attitude on EBF when mothers earned cash and did not take their child with them to work. In contrast, mothers who earned cash in Uganda, irrespective of whether they took their children to work or not were least likely to exclusively breastfeed (Ukwuani et al., 2001). The null hypothesis was rejected as there were many factors that hindered exclusive breastfeeding practice, P = 0.004. CHAPTER FIVE 5.0 SUMMARY, CONCLUSIONS, RECOMMENDATIONS 5.1 SUMMARY According to the research, exclusive breastfeeding is very crucial for the health of babies as mixed feeding results in diseases among babies. Despite the health education done at hospitals and communities on awareness of exclusive breastfeeding up to six months, mothers are reluctant to stick to the teachings. Failure to follow exclusive breastfeeding is attributed to social, cultural and religious factors which promote other feedings as a way of safekeeping of the babies. Working mothers also showed that they have a problem in exclusive breastfeeding their babies since the maternity leave is short and they will have to supplement breast milk with other feeds when they are at work which includes porridge and baby milk bought in shops. The greater number of child bearing mothers is aged between 20-30 years and the research reveals that the mothers are literate but they think that exclusive breastfeeding is associated with the mother being HIV positive. There is also a perception by junior mothers who feel breast milk alone for less than six months is not enough to satisfy the baby. 5.2 CONCLUSIONS One of the greatest factors influencing the attitude of working class mother towards exclusive breastfeeding is their level of education, it is seen to have contributed positively to the acceptance and practice of exclusive breastfeeding as majority of the respondents have junior secondary school certificate. Again, despite their knowledge about exclusive breastfeeding, many of them still have poor knowledge about colostrums. A good number of them even have the misconception that it causes diarrhoea and therefore should not be given to the babies while greater proportion have no reason for rejecting it. In summary, though as much as 93.3% have heard of exclusive breast feeding, up to 31.3% still gave their babies water during the first 4-6 months leaving 74.3% as these who actually breast fed exclusively. 5.3 Recommendations In a way to moderate the attitude of working class mothers towards exclusive breastfeeding, the researcher came up with the following recommendations: 1. Formation of social support group on exclusive feeding 2. Nursing mother working hour of half a working day for the period of 1 year after delivery to enable the mother care adequately for the infant. 3. Health workers especially nurses should try and leave by example. It is discouraging for nurses to preach about exclusive breastfeeding while they themselves do not practice it. 4. Copies of this report should be circulated to all health parastals in the country; this will be informative and educative to every category of health worker as a prelude to the real training of health workers on modern breast feeding management which, is part of the activities of the Breastfeeding promotion And Counseling Group (B.P.C.G.) stated for 1998. 5. Despite the increasing awareness of the practice of exclusive breastfeeding, many nursing mothers still have not come to appreciate the importance and advantages of exclusive breastfeeding over predominant breastfeeding. We therefore suggest that effective health education be adopted to convey this message to the grass roots. Health educators should apply more goal-oriented methods such as person-to -person orientation where misconception and uncertainties can be addressed thoroughly. 6. The teaching about exclusive breastfeeding should be integrated into the school curriculum at all levels as young people tend to practice what they learn at the younger ages. 7. Medical personnel such as public health nurses, community health workers, birth attendants be retrained on the issue about exclusive breastfeeding with emphasis on the relevance of colostrum and as such convey the information to the mothers adequately. Mothers should be encouraged and advised to attend antenatal and postnatal clinics for them to get this information correctly. 8. The baby friendly hospital initiative should be encouraged towards getting all mothers involved in the practice of exclusive breast feeding. Incentives should also be provided for mothers who breastfeed exclusively to encourage them. 9. All mothers, irrespective of their age, marital status, education level and employment status should be encouraged to exclusively breastfeed their infants. Public forums should be used as a channel to promote EBF. 10. There is a great need for health education to explain to mothers the importance of breastfeeding the child on demand to sustain the quantity of breast milk production. This should be done in both antenatal and postnatal clinics in health facilities. Mothers need counseling if they doubt their milk is inadequate or if going back to work. 11. Staff in the ministry of Public Health concerned with child health should be more aggressive in implementing the existing policy on EBF. It should be made clear to the mothers the meaning of exclusive breastfeeding, its recommended period and its health benefits both for the mother and infant. 12. To reduce cases of malnutrition, early introduction of complementary foods to infants by mothers should be discouraged. 13. Provision of crunchiest within the mothers working place. 14. 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