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 Table of Contents  
ORIGINAL ARTICLE
Year : 2019  |  Volume : 12  |  Issue : 3  |  Page : 215-222

Age-appropriate feeding practices of mothers and nutritional status of infants in an urban community in Kano State, North West Nigeria


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

Date of Web Publication15-Oct-2019

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


DOI: 10.4103/kleuhsj.kleuhsj_47_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 an urban community in Kano State.
MATERIALS AND METHODS: A cross-sectional study was conducted in selected communities in Kano Municipal, one of the urban local government areas in Kano State. Using mixed method of data collection, a semi-structured questionnaire was administered to 440 mothers and their infants, and three focus group discussions (FGDs) with ten participants in each group were conducted for mothers of infants. Anthropometric indices were used to determine the children's nutritional status. Data were analyzed using the Statistical Package for the Social Sciences statistical software (version 21), while thematic analysis was used to summarize data from the FGDs.
RESULTS: Majority of the mothers (87.5%) had adequate knowledge of infant feeding practices. Few (16.8%) of the mothers breastfed exclusively, and many (82.5%) of the mothers introduced complementary foods to their infants before 6 months of age. The prevalence of wasting and stunting among infants was 38.9% and 36.4%, respectively. Educational status and antenatal care were associated with 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. Mothers with secondary /tertiary level of education were two times more likely to have good infant feeding practice while mothers that had ANC are four times more likely to have good infant feeding practices Efforts should be made to improve girl child education and develop sustainable strategies to improve feeding practices and nutritional status of children.

Keywords: Infant feeding practice, infants, mothers, nutritional status, urban


How to cite this article:
Ibrahim UA, Gboluwaga AT, Iliyasu Z, Jahun MG. Age-appropriate feeding practices of mothers and nutritional status of infants in an urban community in Kano State, North West Nigeria. Indian J Health Sci Biomed Res 2019;12:215-22

How to cite this URL:
Ibrahim UA, Gboluwaga AT, Iliyasu Z, Jahun MG. Age-appropriate feeding practices of mothers and nutritional status of infants in an urban community in Kano State, North West Nigeria. Indian J Health Sci Biomed Res [serial online] 2019 [cited 2019 Nov 19];12:215-22. Available from: http://www.ijournalhs.org/text.asp?2019/12/3/215/269205




  Introduction Top


Age appropraite feeding is a major determinant of nutritional status. Optimal infant feeding is defined as exclusive breastfeeding (EBF) for 6 months, followed by continued breastfeeding with age-appropriate complementary feeding for up to 2 years.[1],[2] The World Health Organization recommends EBF for the first 6 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. Infancy is a critical period of growth during which nutrient deficiencies and illnesses contribute globally to higher rates of undernutrition among children under 5 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 Goal 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 4 months of life, and in Nigeria, most mothers do not exclusively breastfeed their children for the first 6 months of life.[5] Reports from the 2013 National Demographic and Health Survey showed that only 17% of Nigerian children <6 months of age are exclusively breastfed.[6]

This study determined the mother's nutritional knowledge, infant feeding practices, and how it relates to their nutritional status and the factors associated with infant feeding practice. It is envisaged that the information would be useful to policymakers 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 (LGAs). One LGA was randomly selected from the urban LGAs.[7]

A mixed method study using an adapted [8] pretested, semi-structured, interviewer-administered questionnaire and a focus group discussion (FGD) guide was conducted among urban mothers between May and August 2017 in the selected LGA of Kano State. 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 who were EBF obtained from the past study.[10]

Using multistage sampling technique, respondents were selected. Three political wards were selected from the 13 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 settlements, 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.

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 homogeneous as possible as regards their age and cultural backgrounds. Informed written consent was taken from all the participants. Anthropometric measurements taken were the weight and length, and the Z-score outcome was used as the children's nutritional status according to the WHO criteria on the basis of weight for age, weight for height, and height for age. Babies who were ≧ 1 year old at the time of the study and those whose caregiver did not consent for the study were excluded from the study. Ethical approval was obtained from Aminu Kano Teaching Hospital Health Research 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 analyzed using the Statistical Package for social science version 21 (Armonk, New York; IBM Corp). software package. Absolute numbers and simple percentages were used to describe categorical variables, whereas 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 the 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, whereas 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, whereas 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. The significance level of P was fixed at the 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 and then were transcribed and translated into English. A narrative format was used for reporting the findings.


  Results Top


A total of 440qsuestionnaires were administered to mothers of infants in the urban communities.

Sociodemographic characteristics of the respondents

The age of respondents (mothers) ranged from 17 to 45 years, with a mean of 27.69 ± 6.15. Majority (97.5%) of the respondents were Muslims and of the Hausa tribe (88.4%), and many (56.6%) had at least secondary level of education. Many of the infants (57.3%) were above 6 months of age, and more than half (57.7%) were male [Table 1].
Table 1: Sociodemographic characteristics of the respondents

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Mother's knowledge of recommended infant feeding practices

Majority (87.9%) of the mothers had heard of EBF, and majority (79.1%) knew the correct time for initiation of breastfeeding. Majority (85.7%) knew the ideal time to introduce complementary feeds. The aggregate knowledge score showed that majority (87.5%) of the caregivers had adequate knowledge of infant feeding practices [Table 2].
Table 2: Caregiver's knowledge of recommended infant feeding practices

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Mother's infant feeding practices

Majority of the infants studied were still on breast milk. Many (57.3%) of the mothers breastfed their babies within 30 min of delivery, majority (82.5%) introduced complementary feeding before the age of 6 months only, and a few (16.8%) practiced exclusively breastfeeding. The aggregate practice score showed that many (68.6%) of the mothers had poor infant feeding practices [Table 3].
Table 3: Caregivers infant feeding practices

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Nutritional status of infants

Up to 38.9% had varying degrees of wasting, whereas 36.4% of the infants had varying degrees of stunting [Table 4].
Table 4: Anthropometric measurements of infants (n=440)

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Factors associated with infant feeding practice

Educational status, marital status, and ANC attendance were significantly associated with infant feeding practices [Table 5]. These three factors were further subjected to multivariate analysis to determine predictors for infant feeding practice.
Table 5: Mothers sociodemographic characteristics associated with infant feeding practice

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Predictors of infant feeding practice

Mothers with secondary/tertiary level of education have two times the odds of good infant feeding practice as compared to their counterparts who had informal education. Similarly, mothers who attended ANC are four times more likely to have good infant feeding practices compared to their counterparts who did not attend ANC [Table 6].
Table 6: Predictors of infant feeding practice among urban residents

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Sociodemographic characteristics of the respondents for focus group discussions

The respondents (mothers) were within the age group of 20–45 years, more than two-thirds were from Hausa ethnic group, and more than half of them were homemakers with primary or secondary level of education.

The four themes that emerged from the qualitative data analysis are as follows:

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 min of birth and the duration of exclusive breastfeeding is 6 months.”

Infant feeding practice

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

”I did not EBF my baby because I feel I will harm my child by depriving him of water for 6 months.”

”I started to give my baby pap from the age of 3 months, because I feel I don't produce enough breastmilk.”

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 ANC or through the media. The respondents noted that contributing factors to low EBF rates includes lack of support for breastfeeding mothers, negative beliefs about colostrum, perceived inadequate breast milk production, ignorance of the benefits of EBF, and cultural practices resulting from the influence of respected members of the family.

”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.”

”We used to throw away the first yellowish secretion from the breast, because it is seen as dirty.”

”I would like to practice EBF, but there is no way I can ensure that my relatives who reside in the same house with me will not give my child water in my absence.”


  Discussion Top


We observed in this study that majority 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 among mothers also noted a high awareness about EBF in Jos,[13] Sagamu,[14] and Zambia.[15] Majority of the mothers in this study had heard of EBF and knew the optimal duration for exclusive EBF and the correct age of introducing complementary feeds. Appropraite knowledge on EBF is crucial for child development as it should be the only diet for the first 6 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 EBF has been a focus of many educational campaigns through 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.

In general, the infant feeding practices were poor; many of the mothers initiated breastfeeding late, and a few gave prelacteal feeds. Mothers reported that the delay in initiation of breastfeeding was often because they were usually too weak after delivery to breastfeed. Others felt that breast milk did 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 spiritual water, dates, and fresh honey as a protective measure to the child. Breastfeeding initiation within 30 min of delivery and avoidance of prelacteal feeds has been shown to reduce neonatal morbidity and mortality, stimulate milk production, reduce postpartum bleeding in mothers, and enhance the convolution of the uterus. Prelacteal feeds are usually inappropriate and unsafe and also displace the more nutritive breast milk in the child's diet. Prelacteal feeding practices increase the risk of undernutrition and its associated outcomes.[16] 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. A similar study among an urban population in Nagpur, India, obtained a higher rate of prelacteal feeding.[17] However, breastfeeding initiation within 30 min of delivery in this study was higher than was obtained in an urban community in Kano,[12] Enugu,[5] and India.[18]

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 a fixed schedule. However, a few of the mothers did not see colostrum as beneficial or important to the child's well-being; 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.[19] Despite the strong evidence and wide publicity on the benefits of EBF, the practice was low, only a few of the mothers (16.8%) 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 breast milk 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 a lack of support for breastfeeding mothers.

The prevalence of EBF noted in this study is similar to the findings in Papua New Guinea [20] but lower than the findings from the 2013 Nigerian Demographic and Health Survey [8] and other Nigerian studies from Kano,[14] Birnin Kebbi,[21] Enugu,[5] and other developing countries such as Tanzania [22] and Iraq.[23]

The complementary feeding practices of the mothers were poor as majority of the mothers (82.5%) introduced complementary foods to their infants before 6 months of age. It is common for complementary foods to be introduced too early (e.g., before 4 months) than too late, and also, the complementary foods consumed are often of low nutritional value. The early introduction of complementary feeds observed in this study may be attributable to the strong and widely held belief that breast milk 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 displaces breast milk and affects EBF. The early introduction of complementary feeds observed in this study is higher than that reported in a similar study in Kano,[14] Sokoto,[24] and Southern Ethiopia.[25]

Majority of the caregivers had poor infant feeding practice, and consequentially, the nutritional status of the children was poor. Up to 38.9% and 36.4% 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 as was observed in this study. These complementary feeds are often of poor quality and poorly processed and harbor pathogenic microorganisms resulting in diarrhea which could lead to malnutrition.

A Cameroonian study 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.[26] Interestingly, despite the low prevalence of EBF (22.3% among infants aged 3 months and 0% among infants aged 4–6 months) reported from Morogoro Municipality in Tanzania, over 80% of the infants had normal weights, 13% were stunted, and 8% wasted; these were much lower than that observed in this study.[27] 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. These elders or highly respected people who are perceived to be a source of wisdom and guidance on cultural ways of life can play a critical role in shaping feeding practices and subsequently nutrition outcomes and child health.[28]

Mothers with adequate nutrition education are likely to demonstrate better knowledge and attitudes to key infant and young children's feeding practices.[29] Although majority of the mothers in the studied area appeared to have good nutrition knowledge, this did not seem to translate into appropriate infant feeding practices, and thus, the nutritional status of the infants was poor. Nutrition education which is an element of health promotion should be appropriately delivered and targeted at individuals within a population.

Educational status and antenatal clinic attendance 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. Some studies have demonstrated that 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.[30],[31] The need to strengthen girl child education cannot be overemphasized. The good infant feeding practice observed among mothers who attended ANC may be attributable to the fact that the mothers were educated by health-care workers on the meaning, importance, and need for age-appropriate infant feeding.

It is recommended that health-care workers should not only give nutrition education to mothers and other members of the public but also improve efforts targeted at addressing the identified constraints, correct the misconceptions about breastfeeding, and also ensure that family members encourage and support lactating mothers. The government should provide the Universal Basic Education and ensure that no girl child is left behind.


  Conclusion Top


Majority of the caregivers had adequate knowledge of infant feeding but this was not translated to good practice and thus nutritional status was poor. Mothers with secondary /tertiary level of education were two times more likely to have good infant feeding practice while mothers that had ANC are four times more likely to have good infant feeding practices. 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 infant feeding and also ensure that family members encourage and support lactating mothers. Efforts should be made by government to improve girl child education by providing universal basic education and develop sustainable strategies to improve feeding practices and nutritional status of children.

Acknowledgments

The authors would like to thank all the mothers and infants for their contributions to this study.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]



 

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