Table of Contents  
ORIGINAL ARTICLE
Year : 2019  |  Volume : 21  |  Issue : 2  |  Page : 93-99

Mothers’ feeding practices and nutritional status of infants in a rural community in Kano state north-west Nigeria


1 Department of Paediatrics, Bayero University Kano/Aminu Kano Teaching Hospital, Kano, Nigeria
2 Department of Community Medicine, Bayero University Kano/Aminu Kano Teaching Hospital, Kano, Nigeria

Date of Submission21-Jul-2019
Date of Decision07-Nov-2019
Date of Acceptance09-Nov-2019
Date of Web Publication13-Dec-2019

Correspondence Address:
Umma Abdulsalam Ibrahim
Department of Paediatrics, Bayero University Kano/Aminu Kano Teaching Hospital, PMB 3452, Kano state
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jomt.jomt_26_19

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  Abstract 


Background: Age-appropriate infant feeding practice, a major determinant of child growth, development, and survival remains suboptimal in many developing countries. Objectives: This study determined the mother’s nutritional knowledge, infant feeding practices, nutritional status of their infant, and factors associated with infant feeding practice in a rural community in Kano state. Methods: Using a cross-sectional design with a mixed method approach, data were collected from mothers and their infants in selected communities in Madobi, one of the rural local government area in Kano state. Quantitative data were collected with a semi-structured questionnaire administered to 440 mothers and their infants while qualitative data collection was done using a focus group discussion (FGD) guide with ten participants in each group. Anthropometric indices were used to determine the children’s nutritional status. Data were analyzed using Statistical Package for the Social Sciences (SPSS) statistical software (version 21), while thematic analysis was used to summarize data from the FGDs. Results: Majority of the mothers (78.0%) had adequate knowledge of infant feeding practices. Few (8.9%) of the mothers breastfed exclusively and many (90.8%) of the mothers introduced complementary foods to their infants before six months of age. The prevalence of wasting and stunting among infants was 49.6% and 43.0%, respectively. After bivariate analysis, logistic regression was done, secondary/tertiary education and delivery in the hospital remained predictors of good infant feeding practices. Conclusion: Although, majority of the caregivers had adequate knowledge of infant feeding it was not translated to good practice and thus nutritional status was poor. Efforts should be made to improve girl child education and develop sustainable strategies to improve feeding practices and nutritional status of children.

Keywords: Infants, infant feeding practice, mothers, nutritional status, rural


How to cite this article:
Ibrahim UA, Gboluwaga AT, Iliyasu Z. Mothers’ feeding practices and nutritional status of infants in a rural community in Kano state north-west Nigeria. J Med Trop 2019;21:93-9

How to cite this URL:
Ibrahim UA, Gboluwaga AT, Iliyasu Z. Mothers’ feeding practices and nutritional status of infants in a rural community in Kano state north-west Nigeria. J Med Trop [serial online] 2019 [cited 2020 Apr 10];21:93-9. Available from: http://www.jmedtropics.org/text.asp?2019/21/2/93/272916




  Introduction Top


Infant feeding practice is a major determinant of nutritional status. Optimal infant feeding is defined as exclusive breastfeeding for six months followed by continued breastfeeding with age-appropriate complementary feeding for up to two years.[1],[2] The World Health Organization recommends exclusive breast feeding (EBF) for the first six months of life.[3] This was recommended based on the evidence that good nutrition in the early months of life had a role in achieving good health. The benefits of optimal infant feeding include prevention of disease and infection in childhood and improved cognitive and motor skills development. Infancy is a critical period of growth during which nutrient deficiencies and illnesses contribute globally to higher rates of under nutrition among children under five years of age.[2] Inappropriate infant feeding practices lead to malnutrition which is a significant cause of morbidity and mortality particularly in developing countries. Inappropriate infant feeding and malnutrition can pose a threat to achieving the Sustainable Development Goals (SDG 3) of ensuring healthy lives and promoting the well-being for all at all ages.[4]

Globally an estimated 1.3 million lives are lost annually from lack of EBF and another 600,000 from inappropriate complementary feeding.[3],[4] No more than 35% of infants worldwide are exclusively breastfed, even for the first four months of life.[5] In Nigeria despite the unparalleled benefits of optimal infant feeding and the promotion of EBF, most mothers do not exclusively breastfeed their children for the first six months of life.[5] Reports from the 2013 National Demographic Health Survey (NDHS) showed that only 17% of Nigerian children less than six months of age are exclusively breastfed.[6]

A lot of work has been done on mothers’ knowledge and practices of infant feeding in urban areas but there is a dearth of literature on their counterparts in the rural communities. Thus, this study sought to determine mother’s nutritional knowledge, infant feeding practices, how this relates to the infants’ nutritional status, and the factors associated with infant feeding practice. It is envisaged that the information would be useful to policy makers and program managers especially for the reduction of child morbidity and mortality.


  Materials and methods Top


According to the 2006 Nigeria Population Census, Kano state is the most populous state, with 8 urban and 36 rural local government areas (LGA). Using simple random sampling (balloting) one LGA was randomly selected from the rural LGAs.[7]

A mixed method study using an adapted[8] pretested semi-structured interviewer administered questionnaire and a FGD guide was conducted among rural mothers between May and August 2017 in the selected LGA of Kano state. The questionnaire was pretested on 50 mothers (10%) of the sample size in another rural LGA. The required sample size was arrived at using an appropriate statistical formula for calculating minimum sample size for descriptive studies[9] and prevalence of 54.3% for babies that were EBF obtained from a past study.[10] The calculated sample size was rounded up after adjusting for non-response.

Filled questionnaire were checked during collection on the field to ensure completeness, rule out missing information, and ensure corrections are made before leaving the field on the same day. Using multistage sampling technique respondents were selected. Three political wards were selected from the 12 wards in the LGA by simple random sampling, and then one settlement was selected by simple random sampling from each of the three political wards, giving a total of three settlements. A household list was obtained for each of the settlement, then proportionate allocation of sample size was done for the settlements, and then systematic sampling technique was used to select the required number of household from which the respondents were selected. Sampling interval was obtained by dividing the sampling frame over sample size. Recruitment of the respondents was done until the required sample size was obtained for the settlement. Where respondents refused to consent for the study or when there is no eligible respondent in the household, the next house on the right was visited.

Each session of the FGD was moderated by the researcher and assisted by a note taker who documented details of the discussion. Each session had ten participants and lasted for 45–60 min.

A digital phone recorder was used to record the sessions with the consent of the participants. Participants of each FGD sessions were made as homogenous as possible as regards their age and cultural backgrounds. Informed written consent was taken from all the participants. Anthropometric measurements taken were weight in “kg” and length in “cm” and the Z-scores outcome was used as the children nutritional status according to WHO criteria on the basis of weight for age, weight for height, and height for age. Babies who were more than one year old at the time of the study and those whose caregiver did not consent for the study were excluded from the study.

Five junior community health extension workers (three females and two males) were recruited as research assistants to assist in the data collection process. A three-day training for the research assistants was conducted by the researcher.

Ethical approval was obtained from Aminu Kano Teaching Hospital Health Research and Ethics Committee before conducting the study and permission to carry out the study was given by the Kano State Hospital Management board.

Statistical analysis

The collected data were coded and entered into a spread sheet on Microsoft Excel, cleaned, and analyzed using Statistical Package for the Social Sciences SSPS version 22 software package. Absolute numbers and simple percentages were used to describe categorical variables while quantitative variables were summarized using mean and standard deviation. Knowledge of mothers on infant feeding and infant feeding practice was scored using a scoring and grading system adopted from a past study[11] where one point each was accorded for any correct knowledge or correct practice and zero was accorded for any wrong knowledge and wrong practice. A total of 15 questions assessed mothers’ knowledge of infant feeding; respondents with scores of 0–7 were graded as having inadequate knowledge, while respondents with scores of 8–15 were graded as having adequate knowledge. The infant feeding practices were also assessed using 19 questions; respondents with scores of 0–9 were graded as having poor practice, while respondents with scores of 10–19 were graded as having good practice.

The Chi square test or Fisher’s exact test was used to determine the association between categorical variables as appropriate. Significance level of p was fixed at value of ≤0.05. Binary logistic regression model was used to determine the predictors of good infant feeding practice.

Thematic analysis was used to summarize data from the qualitative interviews. Common themes and answers to specific questions on perceptions and experiences of mothers on infant feeding and nutritional status, perceived factors that influence infant feeding practices, and acceptability of appropriate infant feeding practices were extracted from notes taken from the three FGDs and the transcribed information that was recorded during the FGD session. All FGDs were conducted in Hausa, then were transcribed and translated into English. A narrative format was used for reporting the findings.


  Results Top


A total of 440 questionnaires were administered to mothers of infants in the rural communities.

Socio-demographic characteristics of the respondents

The age of respondents (mothers) ranged from 18 to 50 years with a mean of 29.4±6.96. Majority (96.8%) of the respondents were Muslims and of the Hausa tribe (88.6%). Only 22.5% had at least primary level of education and many (51.4%) were unemployed. Majority of the infants (61.6%) were above six months of age and more than half (53%) were males.

Mother’s knowledge of recommended infant feeding practices

Majority (86.8%) of the mothers had heard of exclusive breastfeeding and many (64.3%) knew the correct time for initiation of breastfeeding, but only few (22.9%) knew the ideal time to introduce complementary feeds. The aggregate knowledge score showed that majority (78.0%) of the caregivers had adequate knowledge of infant feeding practices [Table 1].
Table 1: Mother’s knowledge and practice of recommended infant feeding

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Mother’s infant feeding practices

Majority (99.5%) of the infants studied were still on breastmilk. Many (50.5%) of the mothers breastfed their babies within 30 minutes of delivery and many (57.3%) gave prelacteal feeds. The aggregate practice score showed that majority (88.2%) of the mothers had poor infant feeding practices [Table 1].

Anthropometric measurements of infants

Up to 42.9% of the infants had varying degrees of stunting, while 49.5% had varying degrees of wasting [Table 2].
Table 2: Anthropometric measurements of infants

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Factors associated with infant feeding practice

Educational status, occupation, delivery in the hospital, and knowledge on infant feeding were significantly associated with infant feeding practices [TABLE 3]. These four factors were further subjected to multivariate analysis to determine predictors for infant feeding practice.
Table 3: Factors associated with infant feeding practice

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Predictors of infant feeding practice

Mothers with secondary/tertiary level of education had three times the odds of good infant feeding practice as compared to their counterparts who had informal education. Similarly, mothers who delivered in the hospital were two times more likely to have good infant feeding practices compared to their counterparts who delivered at home [Table 4].
Table 4: Predictors of infant feeding practice

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Sociodemographic characteristics of the respondents for FGDs

The respondents (mothers) were within the age group 20–35 years, more than two thirds were from Hausa ethnic group, and more than half of them were housewives with informal or primary level of education.

The themes that emerged from the specific questions on perception and experiences of mothers on infant feeding are:

Knowledge of mothers on infant feeding practice

Many of the respondents had good knowledge on infant feeding practice. Some of the statements from the FGDs highlighted below exemplify adequate knowledge about breastfeeding:

Breastfeeding should be initiated within 30 minutes of birth and the duration of EBF is 6 months.

In addition to breastmilk, other foods should be introduced at 6 months of age.

Infant feeding practice

Majority of the respondents reported poor infant practice as exemplified below:

I know EBF is beneficial to the baby, but I cannot do it because I feel I will harm my child by depriving him of water for 6 months.

I started to give other foods from the age of 4 months, because it is our family tradition.

Factors associated with infant feeding practice

Some of the respondents were in support of appropriate infant feeding practice but a few of the respondents were not willing to practice appropriate infant feeding. Majority of the respondents explained that the knowledge on infant feeding practices was obtained mostly from the health workers during antenatal clinic (ANC) or via the media. The respondents noted that contributing factors to low EBF rates include lack of support for breastfeeding mothers, negative beliefs about colostrum, perceived inadequate breastmilk production, ignorance of the benefits of EBF, and the influence of respected members of the family.

We used to throw away the first yellowish secretion from the breast, because it is seen as dirty, but we have been educated about its importance so we now give it to our babies.

I commenced plain pap at 3 months because I do not produce enough breastmilk.

I give my baby water from the first day of life so that he will not be thirsty since our environment is hot.

My mother in-law prevented me from breastfeeding my baby until the next day after birth, because the baby has to fast on his first day of life.

My mother taught me to give breastmilk and water for at least 3 months, before any food.


  Discussion Top


We observed in this study that many of the mothers had adequate knowledge of infant feeding practices and this was corroborated by findings from the FGDs. It is known that knowledge influences practice[12] but this was not reflected among the mothers as a much lower proportion of them had good infant feeding practices. Similar studies in Nigeria also noted a high awareness about EBF in Nasarawa[13] and Enugu.[14] Some important facts about infant feeding were however lacking as majority of the mothers did not know the correct age of introducing complementary feeds. Appropriate knowledge on EBF is crucial for child development as it should be the only diet for the first six months of life while complementary feeding should be introduced thereafter. Early commencement or delay of complementary feeding may adversely affect an infant’s growth.

The adequate knowledge of EBF noted may be due to the fact that exclusive breastfeeding has been a focus of many educational campaigns via different media and over several decades. Attendance at ANC was also high and majority of the mothers reported that information on EBF was obtained from health care workers during ANC visit and on the radio.

Generally the infant feeding practices were poor. The mothers explained the delay noted in initiation of breastfeeding by the fact that they were usually too weak after delivery to breastfeed and they often gave prelacteal feeds because they felt “breast milk does not flow immediately after birth” and labor being a stressful process makes babies “very thirsty”. Others believed that the first thing a child takes by mouth is crucial in preventing the child from been attacked by evil ones, so they give dates and fresh honey as a protective measure to the child. Breastfeeding initiation within 30 minutes of delivery and avoidance of prelacteal feeds have been shown to reduce neonatal morbidity and mortality, stimulate milk production, reduce postpartum bleeding in mothers, and enhance evolution of the uterus. Prelacteal feeds are usually inappropriate, unsafe, and also displace the more nutritive breast milk in the child’s diet. Pre-lacteal feeding practices increase the risk of under nutrition and its associated outcomes.[15] The level of prelacteal feeding in this study is in consonance with that of a previous study in Kano[12] likely because of the similarity of the study population and their cultural practices. Breastfeeding initiation within 30 minutes of delivery in this study was higher than was obtained in an urban community in Kano [12] and a rural community in Sokoto[16] northwest Nigeria.

Majority of the mothers fed their babies with colostrum and breastfed on demand as they recognized the benefits. They mentioned that colostrum was important, nutritive, and essential and on demand breastfeeding often led to earlier maximum milk production than feeding on fixed schedule. However a few of the mothers did not see colostrum as beneficial or important to the child’s wellbeing; some even saw it as being harmful and resorted to expressing the milk and discarding it. During the FGD, mothers reported that this practice was upheld and enforced by mothers-in-law, aunts, or other elderly women and relatives.

EBF has been described as the single most important cost-effective intervention to reduce infant mortality particularly in developing countries.[17] Despite the strong evidence and wide publicity on the benefits of EBF, the practice was low, only a few of the mothers (8.9%) breastfed exclusively. This may be attributable to the fact that majority of the mothers feared that babies would be thirsty because they believed that the water in the breastmilk was not sufficient to avoid dehydration especially during hot weather. During the FGD, some discussants indicated that the EBF practice was low because EBF is not culturally acceptable, some mothers may not have adequate breast milk, and there was lack of support for breastfeeding mothers.

The prevalence of exclusive breastfeeding noted in this study is lower than the findings from the 2013 Nigerian Demographic and Health Survey[6] and other studies from Nigeria in Kano,[12] Enugu,[14] and Kware[18] and from other developing countries like Bangladesh[19] and Bangalore city in India. [20]

The complementary feeding practices of the mothers were poor as majority of the mothers (90.8%) introduced complementary foods to their infants before six months of age. It is common for complementary foods to be introduced too early (e.g. before four months) than too late, and also the complementary foods consumed are often of low nutritional value.[5] The early introduction of complementary feeds observed in this study may be attributable to the strong and widely held belief that breastmilk is insufficient and hence the need to commence complimentary feeding. This was reported by the mothers during the FGDs. Early complementary feeding observed in this study is harmful in many ways as food and water displace breastmilk and affect EBF breastfeeding. The early introduction of complementary feeds observed in this study is higher than that reported in a similar Nigerian study in Kano[21] and Enugu.[14]

Majority of the caregivers had poor infant feeding practice and consequentially the nutritional status of the children was poor. Up to 49.5% and 42.9% of the infants were wasted and stunted respectively. This shows that malnutrition begins early in life with poor infant feeding practices such as the lack of EBF and the institution of complementary feeds earlier than recommended by the National Policy on infant and young child feeding as was observed in this study. The poor nutritional status observed in this study may have resulted from the early introduction of complementary feeds possibly of poor quality, poorly processed and might even harbor pathogenic micro-organisms resulting in diarrhea which could lead to malnutrition.

A study in Cameroonian noted that the level of underweight, stunting, and wasting among infants was high and attributed this to poor complementary feeding as observed in this study.[22] Interestingly, despite the low prevalence of EBF (7.6%) reported from Limpopo district in South Africa the figures for underweight (7%), stunting (18.9%), and wasting (7%) were much lower than that observed in this study.[23] This may be attributable to the differences in pattern of complementary feeding.During the FGD it was noted that cultural practices resulting from the influence of respected members of the family stood out as a significant barrier to the use of appropriate infant and young child feeding practices. These cultural practices which are sometimes harmful seem to be entrenched in the beliefs of the elders or highly respected people in the family. The elders are perceived to be a source of wisdom and guidance on cultural ways of life and they play a critical role in shaping feeding practices, nutrition outcomes, and child health.[24]

Although, majority of the mothers in the studied area appeared to have good nutrition knowledge, this knowledge did not seem to translate into appropriate infant feeding practices and thus the nutritional status of the infants was poor. Nutrition education appropriately delivered is an element of health promotion targeting individual people within a population. Mothers with adequate nutrition education are likely to demonstrate better knowledge and attitudes to key infant and young children feeding practices.[25]

Educational status and delivery in the hospital were significantly associated with infant feeding practice. This is likely because mother’s education plays a vital role in increasing receptivity to knowledge and also influences the practices. Maternal education is one of the strongest determinants of the practice of EBF because educated women are much more likely to practice EBF than those who are uneducated.[26] Therefore, the need to strengthen girl child education cannot be over emphasized.


  Conclusion and recommendation Top


Knowledge on infant feeding was good, however the age-appropriate infant feeding practices were poor and consequentially the nutritional status of the infants was poor. It is recommended that healthcare workers should not only give nutrition education to mothers and other members of the public, but improve efforts targeted at addressing the identified constraints, correct the misconceptions about breastfeeding, and also ensure that family members encourage and support lactating mothers. Efforts at educating the girl should also be strengthened by all stakeholders.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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  [Table 1], [Table 2], [TABLE 3], [Table 4]



 

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