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CHAPTER ONE INTRODUCTION
1.1 Background to the study
Breastfeeding according to WHO (1987) is as old as society and it is a natural method of feeding infants in all human societies. Breastfeeding is central to many human rights issues addressed in different rights conventions. The human rights system was a creation of the 20th century and a comprehensive international development within the United Nations (UN). The creation was in response to the devastation and inhumanity inflicted by World War II, hence there was consensus that rules and standards should be established which would uphold human dignity, protect all people from such harm. Thus a treaty system was then introduced allowing any member state of the United Nations (Nigeria inclusive) to undertake legal obligations to respect, protect and fulfill the most important human rights (United Nations, 2007).
One of the human rights conventions is the convention on the rights of the child (CRC) which sets out basic human rights for children including the rights to survival, development to the fullest, protection from harmful influences, abuse and exploitation, full participation in family cultural and social lives (United Nations, 2007:4). Other provisions on health, nutrition, education, information and gender discriminations also have implications for breastfeeding rights (Johnson, 1998;United Nations, 2007).
Breastfeeding is therefore far from being only a childrens’ issue, it is also about women and their world. The position and condition of women, including their nutrition, health and survival are major determinants of every child’s welfare. Therefore, attention to women’s health and nutrition as well as their socio-cultural realities is of immense benefit to the entire family and society at large. According to WHO/UNICEF (2004), one of the four basic principles of the convention on the right of the child (CRC) is the child’s inherent right to life, survival and development, as stated in article 6 (1) and 6 (2) of the document. This is interpreted as placing a responsibility on countries, to reduce infant mortality, increase life expectancy and eliminate malnutrition, illness and epidemics. In article 24 of the CRC, the importance of breastfeeding in ensuring the child’s right to the highest attainable standard of health is mentioned specifically. Prior to the current promotion of breastfeeding trend with resultant innovation of exclusive breastfeeding (EBF), African women had been fully engaged in the practice of breastfeeding of their infants without reservations. Eze (2004) substantiated this fact by stating that, the pediatric care of sustained suckling of infants which orthodox western medicine has currently confirmed its benefits and which international organizations now spend millions of dollars to promote was actually the routine practice in the traditional African communities (Ezeh, 2004:73).
Although breastfeeding practice is the norm in the traditional African societies, the fact remains that EBF which involves total denial of water and other supplements to the infants under six months of age was never practiced. This is because a traditional African woman does not believe that an infant under six months of age can survive without water (Alutu, 2000). Exclusive breastfeeding has been defined by many researchers as the application of breast milk alone in the feeding of infants for the first six months of the infant’s life, after which solid foods and other supplements and water would be introduced (WHO, 2003; Perez, Luther, Trevion &Sanghvi, 1998; UNICEF, 2005; WHO, 2002).
In recent years, the promotion of breastfeeding, particularly, EBF has been the focus of many international organizations, health professionals, multilateral organizations like WHO, UNICEF as well as academics, governments and non-governmental organization (NGOs). These groups were said to be concerned by infant death, malnutrition and infections due to lack of optimal infant and young child feeding. The World Health Assembly (WHA) also adopted a global strategy (GS) on infant and young child feeding which stresses on the need to empower women to practice EBF. It considers good nutrition an essential component of the health and human rights of women and children and a key contribution to poverty reduction (UNICEF, 2005). To enhance EBF, UNICEF initiated the Baby-Friendly Hospital Initiative (BFHI) as a primary intervention strategy for promoting and strengthening health systems for EBF practices (Duncan, 2004). UNICEF also initiated ten steps to successful breastfeeding as guidelines for EBF practices (UNICEF 2005:126).
Considering its advantages, EBF is an adequate way of providing ideal food for the healthy growth and development of infants for the first six months of life. According to Alutu (2000), there can be no infant food more locally produced, more sustainable or more environmentally friendly than a mother’s breast milk. It is naturally renewable, resourceful, free, requires no packaging or transport and resulting in no wastage. There is no doubt that the knowledge of the advantages of EBF can help mothers in adopting the practice.
Although EBF has many advantages, Nwachukwu and Nwachukwu (2004) submitted
that EBF has some adverse effects on malnourished and sick mothers. According to them, EBF takes a lot out of these mothers and family income. Other effects include lower abdominal pain/cramps during breastfeeding, engorged and painful breast and interference with a mother’s employment. Besides, some women who are willing to breastfeed for long time are unable to do so due to the following reasons; insufficient breastmilk, poor nutrition, stress, inconveniences, interference with work or studies and tiredness including maternal employment
Despite the numerous advantages of EBF, Grange (2005) lamented that the goals of EBF have still not been reached. Millions of infants are at risks of illness and death due to this gap. The question that arises is: what factors are responsible for the low practice of EBF among mothers? This is necessary since Njepuame (2005) posited that the success of any programme to a large extent depends on identification of factors that are germane for its successful implementation. Possible predictor variables could be sourced from social, cultural and demographic circumstances of the mothers. For instance, such social factors as educational status, occupation, marital status, age, location and parity (number of children) are deemed to be capable of influencing adoption of EBF (Nwagu, 2006). The cultural factors include extended family system, father dominance in the family, mothers’ multiple role, influence of western culture and so on (Oranu, 1999).
Consequently, these socio-cultural factors pose a big challenge to social work profession as Okafor (2002) remarked that the influence of socio-cultural beliefs, religion, taboos and superstitions have serious implications for social work services in general. The medical social workers should therefore study the socio-cultural factors in the communities which affect EBF practices, and so engage in helping mothers to overcome the challenges of the socio-cultural factors and adopt EBF through counseling, educating, mediating, collaborating and advocacy
Available literature shows that there are few reports on the practice of EBF in Nigeria, and specially the socio-cultural dimensions. This study is therefore aimed at the investigation of the socio-cultural factors associated with the practice of exclusive breastfeeding in EnuguState.
1.2 Statement of the problem
It is surprising that in spite of the enormous efforts and well-articulatedprogrammes to promote, protect and support breastfeeding in Nigeria, many mothers still find it very difficult to practice exclusive breastfeeding (EBF) (UNICEF, 2005:91). A recent demographic survey by Nwankwo (2006) also revealed that the practice of exclusive breastfeeding in Nigeria is not in compliance with WHO and UNICEF recommendation. The recommendation states that a new born baby should be put to breast within nine hours after delivery, and should be exclusively breastfed on demand until six months of age after which supplementary feed and water should be introduced, also breastfeeding should continue for up to two years (WHO/UNICEF, 2004).
Regrettably, data from the latest demographic survey in Nigeria revealed that only 17 percent of infants below six months of age and just one quarter of infants undertwo monthsof age are exclusively breastfed as a result of early supplementation of breast milk with water. The above figure could be disturbing for anyone who is interested in the health status and well-being of children. Incidentally, this may be one of the reasons why infant mortality is rated very high in
the country as was documented by WHO (2001), Obionu (2006), Onyeneho (2005), FMOH(2002) and Igbokwe (2008).
Interestingly, one of the aims of the Millennium Development Goals (MDGs) is to reduce Infant Mortality Rate (IMR) by three quarter by 2015. Onyeneho (2005) reported that Nigeria like many other Sub-Saharan African countries witnessed a dramatic increase in infant and child mortality in the 1990s and early 2000s. While the infant mortality ratio of 715 infant deaths per 100,000 live births was obtained from national survey in 1999 as indicated by UNICEF (2001), a recent document of the FMOH (2006) stated that there is dire and urgent need to effectively address the high infant mortality (IM) in Nigeria in the interest of human development, social justice and poverty alleviation. Incidentally, WHO (2001) identified that EBF is capable of reducing infant mortality rate by preventing the common childhood illnesses, such as diarrhea, gastro-intestinal diseases, pneumonia, etc and also helps to quicken recovery during illnesses.
A former minister of Health in Nigeria, Professor Eyitayo Lambo in a paper presented at the National Breastfeeding Week held in Abuja in 2005, declared the low rate of EBF recorded among infants below six months in Nigeria. He further described EBF as invaluable as it is the safest infant feeding choice, especially in crisis situations where the safe preparation of artificial food is difficult, or if the level of infectious diseases is high. A study by Armstrong (2002) also indicated that in Africa, the practice of EBF ranges between 20-90 percent while in Nigeria, the rate is 17 percent in the first four months of life, and only 26 percent of infants less than two months are exclusively breastfed (WHO, 2001).
Certain constraints have been identified in literature that are associated with the low level of EBF practices among mothers. Guashiddin and Kabir (2004) and Gosh, Gidwani and Shineen (2005) pointed out that the decision to practice EBF is very often influenced more by sociocultural factors than by health considerations. In their studies in Bangladesh and India, they reported that education, employment/occupation, and lack of information have and continued to interfere with the optimal breastfeeding practices among mothers. Other cultural factors that influence EBF include preference of male child, father’s dominance in the family, influence of extended families, mother’s multiple roles, influence of poorly trained health workers including traditional birth attendants, influence of western culture and other cultural beliefs such as belief that colostrums is not good for the baby, expressed breast milk could be poisoned and belief in the use of water and other liquids (Gupter, Katende&Bessinger, 2004; Guashuddinlabir, Rahman
Although these factors are identified in literature as factors affecting the mother’s adoption of EBF, their effects may differ from society to society and even within the same society. The study proposed here was thus designed to investigate those socio-cultural factors that are associated with the practice of EBF among nursing mothers in EnuguState and assess the relevance of existing policies on EBF in the State.
1.3 Research questions
The following questions are formulated to guide the study.
1. What is the extent of EBF practice in Enugu State? Comment [PNE2]: I do not think you have
enough data to discuss rate of EBF practice.
2. What is the attitude of mothers toward EBF practice in Enugu State?
3. What is the belief of mothers toward EBF practice in EnuguState?
4. What are the factors associated with mothers’ practice of EBF in EnuguState?
5. What is the link between parity (number of children) and EBF practice among mothers in
6. What is the influence of TBAs on the mothers’ practice of EBF in EnuguState?
7. What is the role of social workers in the mother’s practice of EBF?
1.4 Objectives of the study
The general objective of this study was to examine the socio-cultural factors that are associated with EBF practice among mothers in EnuguState.
Specifically, the study will:
1. Ascertain the extent to which EBF is practiced among mothers in Enugu State.
2. Ascertain the beliefs and attitude of mothers toward EBF in EnuguState.
3. Identify the factors that affect EBF practice in EnuguState.
4. Find out the link between parity and EBF practice in EnuguState.
5. Ascertain the influence of TBAs on the mothers’ practice of EBF in EnuguState.
6. Identify the role of social workers in the mother’s practice of EBF in EnuguState.
1.5 Significance of the study
Generally, the study generated data on breastfeeding practices of nursing mothers and the socio-cultural factors associated with them. A study of this nature will have both practical and theoretical significance.
Practically, the study is intended to serve as a catalyst for increased action in support of Innocenti Declaration and the global strategy for infants and young children’s feeding. Social workers and health care practitioners will find the study very useful in sensitizing mothers on breastfeeding issues. The information from the study will also be useful to all those who are interested in propagating the principles of exclusive breastfeeding.
Data emanating from this study will be useful to health workers especially the nurses, midwives, and community health practitioners in determining their focus of attention in the provision of Maternal and Child Health (MCH) services. Findings from the study will urge the national and state authorities to reinforce all actions that protect, promote and support breastfeeding within complementary programmes. Such programmes include prenatal and postnatal care, nutrition, family planning services and prevention and treatment of common maternal and childhood diseases.
Theoretically, the study will generate more data on the WHO/UNICEF ten steps to successful and optimal breastfeeding. Findings from the study will enrich the existing information on EBF. Subsequent researchers will also use the findings from the study to test the existing theories on health promotion. Finally, data from the study will be used by future researchers to explore other areas of EBF which will not be covered in the present study.
1.6 Definition of concepts
This is a natural act of feeding an infant on milk from the breast of a lactating mother. It is a complete food for the infant.
This refers to the practice of feeding an infant on only breast milk, from birth until six months of age. No water or any other liquid or solid food except vitamin drop should be given to the infant during this period.
Social means the government conditions and demographic factors such as sex, education, income, occupation, etc. Culture is a system of norms, values and customs that are socially learned by members of a group and transmitted from generation to generation including their beliefs, attitudes and life styles. It is a way of life of a group of people. Factors are things that influence a situation. Socio-cultural factors in this study are the various ways in which EBF practice may be influenced and affected by traditions, beliefs and human resources, etc.
This is defined as a mental state of readiness, organized through experiences, exerting a directive or dynamic influence upon the individual’s responses to an object and situations with which it is related. Attitude when related to this study is called breastfeeding attitude which is seen as the feelings, beliefs, behaviours, thoughts and experiences of mothers towards EBF practice.
This is referred to as doing what is sensible, workable, useful and suitable and good at repairing or making things. Practice in the present study portrays the behavior of mothers towards the practice of EBF.
To nurse is to feed a baby at the breast or to suckle a baby at the breast or to suckle a baby. Therefore, nursing mothers are referred to as mothers of children from zero to two years age who are still giving their babies breast milk.
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