Exclusive Breastfeeding Intentions Among Adolescents In Urban Communities In Ibadan, Nigeria.

Purpose: During adolescence, a female child makes several decisions, and the choice to breastfeed in the near future is conceivably shaped. But in sub-Saharan Africa where teenage pregnancy and teenage motherhood is on the rise, there is a dearth of information on the intention of adolescents to exclusively breastfeed (EBF) in community settings. Therefore, this study assessed exclusive breastfeeding intentions, knowledge and attitude of adolescents in urban communities in Ibadan, Nigeria.
Methods: A descriptive community-based cross-sectional study was carried out, selecting 271 respondents. Data were analysed with the aid of IBM SPSS version 21 at P ≤ .05.
Results: Mean age of adolescents was 17.5 ± 1.3 years, and 96.3% would breastfeed their children later in future. However, only 37.6%, 22.5% and 50.2% had the intention to exclusively breastfeed, good knowledge score and positive attitude, respectively. There were significant relationships between respondents' age, educational attainment, parents' educational attainment, level of knowledge, attitude and intention. The coefficient of knowledge and attitude were significant predictors of good intention to practise EBF. Major predictors of good intention were good knowledge [OR = 36.5; 95% CI (9.2, 145.2)] and positive attitude toward EBF [OR = 9.7; 95% CI (3.6, 25.9)]. Conclusions: The EBF intention was influenced by multiple factors and should be considered in determining the effectiveness of interventions targeting this practice. Therefore, coherent EBF education interventions that commence from adolescence to promote the practice by adulthood are urgently needed to improve knowledge, attitude and intention about EBF rate and confer the cancer-risk reducing benefits.

What do we already know about this topic?

Exclusive breastfeeding (EBF) rates are poor in low- and middle-income countries, and according to the Federal Ministry of Health of Nigeria, it is 29% which is below the global target of 70%.

How does your research contribute to the field?

Life decisions are formed plausibly in adolescence, and these are reliant upon information acquired at this stage; however, there is a dearth of information on adolescents’ EBF intentions in community settings. The study sought to assess the intention, knowledge and attitude of adolescents toward exclusive breastfeeding on this basis. The findings of the study indicated gaps in intention, knowledge and attitude, suggesting that interventions should be directed toward this age group to reduce suboptimal feeding practices

What are your research’s implications towards theory, practice, or policy?

The findings suggest that EBF education interventions that commence from adolescence are necessary to promote the practice that is effective in preventing child morbidity and mortality.

Introduction

Breastfeeding is a healthy practice, and understanding the views of adolescents can proffer prompt steps for intervention as suboptimal breastfeeding practices are becoming widespread in Nigeria. This is because the choice to breastfeed is shaped conceivably in adolescence.

Globally, less than 40% of infants aged 0 to 6 months are exclusively breastfed which is way below the 2030 global target of 70%. Findings have indicated that non-exclusive breastfeeding contributes to 11.6% of mortality in children under 5 years of age. Statistics from WHO reveals that low- to middle-income countries have 95% of births to mothers below 20 years of age, and the highest rates occur in sub-Saharan Africa. Nonetheless, optimal breastfeeding has the potential to save over 820,000 children under the age of 5 years each year.

In Nigeria, EBF is seemingly low at 17%, and World Bank indicators showed that teenage mothers make up 22.9% of women in Nigeria. This low EBF rate and increase in teenage pregnancy suggest that EBF intention of adolescent needs to be captured. Studies have indicated that having the right information improves knowledge and fosters good attitude, which play a vital role in the intention to breastfeed. Inaccurate information on EBF, age of mothers and inadequate supportive environment from significant others are some factors associated with the practice of EBF.[6,7] Being 35 years and older and having an unplanned pregnancy were found to reduce the likelihood of having a strong intention to exclusively breastfeed an infant.

In addition, breastfeeding is an internationally recognized and supported practice. WHO recommends breastfeeding exclusively for the first 6 months and afterwards continued for a minimum of 2 years from the child’s birth, with the introduction of complementary foods that are safe, appropriate and adequate from the age of 6 months.

These recommendations are due to the established facts of the numerous benefits it has for the newborn as well as the mother. When breastfed as a child, there is lower risk of being overweight or obese, better performance on intelligence tests and higher school attendance. Breastfeeding is also associated with higher income in adult life. The reduction in health costs when a child’s development is improved also contributes to economic gains for individual families as well as at the national level. For the mother, the risk of ovarian and breast cancer is reduced as a result of breastfeeding, and it also enhances child-spacing through a hormonal effect which often induces a lack of menstruation.

To make an informed decision, facts are essential. During adolescence, a female child makes several decisions, and the choice to breastfeed in the near future is conceivably shaped. But in sub-Saharan Africa where teenage pregnancy and teenage motherhood is on the rise, there is a dearth of information on the intention of adolescents to exclusively breastfeed (EBF). However, the knowledge and attitude toward breastfeeding of adolescents is an important domain to champion the cause of breastfeeding as a child survival strategy. Therefore, this study sought to assess exclusive breastfeeding intentions, knowledge and attitude among adolescent girls in urban communities in Ibadan, Nigeria.

Methods

Design

The community-based cross-sectional study employed a semi-structured interviewer-administered questionnaire that measured the intention, knowledge and attitude to exclusively breastfeed among 271 Nigerian adolescents aged 15-19 years in urban communities in Ibadan, Nigeria. The sample size for this study was estimated using the Leslie Kish formula using proportions from a previous study among adolescent school girls. Being within the 15- to 19-year age range and never given birth nor breastfed before served as the inclusion criteria for this study. A multi-stage (4-stage) sampling technique was used to select respondents from the communities.

Written informed consent was obtained from respondents aged 18 years and parents/guardians of respondents who were underage, while verbal informed consent was obtained from underage respondents. Prior to this, the field assistants were trained, and the questionnaire, pre-tested and standardized. Descriptive statistics, chi-square test and logistic regression at 5% level of significance were used to analyse data. The study was carried out between May 2019 and January 2020.

Instrument for Data Collection

A validated semi-structured, interviewer-administered questionnaire was utilized to acquire data which was divided into 4 sections. The questionnaire was adapted from previous studies on exclusive breastfeeding and outside the study location; this questionnaire was pre-tested among 26 female adolescents. Reliability co-efficient of .73 was used to judge the questionnaire as being reliable.

The intention of adolescents on breastfeeding was measured with a 10-item question. Responses were classified as agree and disagree. Each response is scored 1, making a total of 10. A score ≤ 5 was regarded as poor, and a score ≥ 6 was regarded as good. A 26-item question was used to measure the knowledge of adolescents on EBF. Responses were classified as yes and no. Each response is scored 1, making a total of 26. A score ≤ 12 was rated as poor and a score ≥ 13 was rated as good. A 13-item question was used to measure the attitude of adolescents on breastfeeding. Each response is scored 1, making a total of 13. A score ≤ 6 was regarded as negative attitude, and a score ≥ 7 was regarded as positive attitude.

Method of Data Collection

The data collection was carried out by the researcher and 3 research assistants. The research assistants were trained prior to the time of the data collection. The criteria for selecting the research assistants were experience in collecting data at community setting, good communication skills, knowledge of research ethics and respect for persons. The questionnaire was serially numbered, and copies of the questionnaire were administered after obtaining informed consent. After the copies of the questionnaire had been filled, the researcher checked for completeness and errors before leaving the field.

Data Analysis

The analysis in descriptive statistics such as mean, median and mode and inferential statistics such as chi-square was computed. The chi-square was used to judge the association of variables. The Wald statistic in logistics regression was used to indicate if the coefficient of certain variables was significant. The results obtained from the Statistical Package for Social Science (SPSS version 21) analysis were summarized and presented in prose, tables and charts.

Results

The age of respondents ranged from 15 years to 19 years with a mean age of 17.5 ± 1.3 years. Majority (89.7%) of the respondents were of Yoruba ethnic background, followed by Igbo (7.4%) and Hausa (.7%). Christianity was the most prominent religion practised by the respondents (58.3%). There were one hundred and seventy-five (64.6%) respondents who had secondary education; however, a small proportion of the respondents (1.1%) did not have any form of formal education. The respondents were predominantly students, 150 (55.4%), followed by those out-of-school, 66 (24.4%), and 263 (97%) were single. Fathers’ and mothers’ highest level of education were secondary, 149 (55.4%) and 152 (56.1%), respectively (Table 1).

Table 1.

Respondents’ Socio-Demographic Characteristics (N = 271).

Socio-Demographic Characteristics	Frequency	Percentage
Age (years)
15	18	6.6
16	63	23.2
17	42	15.5
18	68	25.1
19	80	29.5
Religion
Christianity	158	58.3
Islam	113	41.7
Highest educational attainment
No formal education	3	1.1
Primary school	5	1.8
Junior secondary school	65	24
Senior secondary school	175	64.6
Tertiary	23	8.5
Marital status
Single	263	97.0
Married	8	3.0
Fathers highest educational attainment
No formal education	7	2.6
Primary	23	8.5
Secondary	149	55.4
Colleges of education	30	11.1
Bachelor’s degree	44	16.2
Postgraduate	18	6.6
Mothers’ highest educational attainment
No formal education	5	1.8
Primary	31	11.4
Secondary	152	56.1
OND/Colleges of edu	29	10.7
Bachelor’s degree	38	14.0
Postgraduate	16	5.9

Mean age 17.5 ± 1.3.

Adolescents’ knowledge in the current study toward breastfeeding is not in line with the current international recommendations. Only 22.5% of the respondents had good breastfeeding knowledge. In assessing attitude toward breastfeeding, positive and negative score were not far apart although more of the respondents (50.2%) had positive attitude. However, EBF intention was poor (37.6%) (Table 1).

Test of Hypothesis

It was found that there is a statistical relationship between respondents’ exclusive breastfeeding intention and age (X2 = 11.4, P-value = .023), religion (X2 = 4.7, P-value = .030), education (X2 = 15.0, P-value = .005), father’s education (X2 = 11.6, P-value = .037) and mother’s education (X2 = 14.2, P-value = .012). Similarly, respondents’ intention and knowledge of exclusive breastfeeding has a significant influence (X2 = 137.2, P-value = < .001). Additionally, it was found that there is a statistical relationship between respondents’ exclusive breastfeeding intention and attitude (X2 = 94.7, P-value = < .001) (Table 2).

Table 2.

Chi-Square Test (X2) was Used in Testing Hypothesis at 95% Confidence Interval (P < .05).

	Intention to Breastfeed
Variable	Good (%)	Poor (%)	Total	X2	df	P-value
Age
15	6 (33.3)	12 (66.7)	18 (6.6)	11.4	4	.023*
16	14 (22.2)	49 (77.8)	63 (23.2)
17	14 (33.3)	28 (66.7)	42 (15.5)
18	30 (44.1)	38 (55.9)	68 (25.0)
19	38 (47.5)	42 (52.5)	80 (29.5)
Religion
Christianity	68 (43.0)	90 (57)	158 (58.3)	4.7	1	.030*
Islam	34 (30.0)	79 (70.0)	113 (41.7)
Highest educational attainment
No formal education	1 (33.3)	2 (66.7)	3 (1.1)	15.0	4	.005* a
Primary	0 (0)	5 (100.0)	5 (1.8)
Junior sec	19 (29.2)	46 (70.8)	65 (24.0)
Senior sec	66 (37.7)	109 (62.3)	175 (64.6)
Tertiary	16 (69.6)	7 (30.4)	23 (8.5)
Fathers’ highest educational attainment
No formal education	2 (28.6)	5 (71.4)	7 (2.6)	11.6	5	.037* a
Primary	5 (21.7)	18 (78.3)	23 (8.5)
Secondary	59 (39.6)	90 (60.4)	149 (55.0)
Colleges of education	6 (20.0)	24 (80.0)	28 (11.1)
Bachelor’s degree	19 (43.2)	25 (56.8)	44 (16.2)
Postgraduate	11 (61.1)	7 (38.9)	18 (6.6)
Mothers’ highest educational attainment
No formal education	1 (20.0)	4 (80.0)	5 (1.8)	14.2	5	.012* a
Primary	4 (12.9)	227 (87.1)	31 (11.4)
Secondary	59 (38.8)	93 (61.2)	151 (56.1)
Colleges of education	10 (34.5)	19 (65.5)	29 (10.7)
Bachelor’s degree	20 (52.6)	18 (47.4)	38 (14.0)
Postgraduate	8 (50.0)	8 (50.0)	16 (5.9)
Knowledge score
Poor	1 (1.4)	73 (98.6)	74 (27.3)	137.2	2	< .001* a
Fair	45 (33.1)	91 (66.9)	136 (50.2)
Good	56 (91.8)	5 (8.2)	61 (22.5)
Attitude score
Negative	12 (8.9)	123 (91.1)	135 (49.8)	94.7	1	< .001*
Positive	90 (66.2)	46 (33.8)	136 (50.2)

*Significant. Fishers Exact Test.

Logistic regression was used to assess association of knowledge, attitude and socio-demographic variables on intention to breastfeed. The coefficient of knowledge and attitude (P < .001) were both significant predictors of good intention to practise EBF in the logistic regression model. Major predictors of good intention were good knowledge [OR = 36.5, 95% CI (9.2, 145.2)] and positive attitude towards EBF [OR = 9.7; 95% CI (3.6, 25.9)] (Table 3).

Table 3.

Logistic Regression Model on Intention of Exclusive Breastfeeding.

Variable	B	S.E.	Wald	Df	P-value	Exp (B)	95% CI for EXP (B)
							Lower	Upper
Age	−.089	.181	.241	1	.623	.915	.641	1.305
Religion (Muslim)	−.478	.459	1.087	1	.297	.620	.252	1.523
Education			4.907	4	.297
No formal education	2.141	1.921	1.243	1	.265	8.511	.197	367.448
Primary	−15.235	15759.887	.000	1	.999	.000	.000	.
Junior sec	2.256	1.118	4.074	1	.044	9.548	1.068	85.393
Senior sec	2.293	1.044	4.825	1	.028	9.908	1.280	76.673
Occupation			6.367	3	.095
Out-of-School	1.077	.629	2.935	1	.087	2.936	.856	10.068
Apprentice	1.570	.654	5.753	1	.016	4.805	1.332	17.328
Others	1.063	1.748	.370	1	.543	2.894	.094	88.990
Father’s education			7.451	6	.281
Primary	−25.613	40193.472	.000	1	.999	.000	.000	.
Secondary	−25.711	40193.472	.000	1	.999	.000	.000	.
OND/Colleges of edu	−28.530	40193.472	.000	1	.999	.000	.000	.
Bachelor’s degree	−27.511	40193.472	.000	1	.999	.000	.000	.
Postgraduate	−27.228	40193.472	.000	1	.999	.000	.000	.
Others	−27.156	40193.472	.000	1	.999	.000	.000	.
Mother’s education			6.519	6	.368
Primary	−1.103	1.822	.367	1	.545	.332	.009	11.795
Secondary	.791	1.635	.234	1	.628	2.206	.090	54.345
OND/Colleges of edu	2.331	1.938	1.446	1	.229	10.286	.230	459.160
Bachelor’s degree	2.620	1.989	1.736	1	.188	13.740	.279	677.130
Postgraduate	2.413	2.240	1.160	1	.282	11.165	.138	901.450
Others	1.005	2.358	.182	1	.670	2.731	.027	277.530
Knowledge	3.598	.704	26.114	1	.000	36.524	9.189	145.177
Attitude	2.271	.502	20.444	1	.000	9.693	3.621	25.946
Constant	12.635	40193.472	.000	1	1.000	307176.160

Predictors: age, religion, education, father’s education and mother’s education, knowledge score and attitude score.

Variable type used: categorical (religion, education, father’s education and mother’s education); numeric (age, knowledge score and attitude score).

Reference category: education (tertiary); father’s education (no formal education) and mother’s education (no formal education).

Discussion

The study assessed the intention of adolescents to breastfeed exclusively, as well as their knowledge and attitude as adequate information before motherhood is liable to improve breastfeeding practice. Breastfeeding is viewed as the public health measure with the most cost-effectiveness, which fundamentally impacts infant morbidity and mortality in developing nations.[11,12] Breastfeeding knowledge of younger people has been closely linked with attitude and intention.[13,14] Findings from this study showed a significant level of awareness; however, detailed assessment suggested many of the respondents lack adequate knowledge about breastfeeding. This affirms the likelihood noted in a study of a decrease in the extent of Nigerian women with adequate breastfeeding knowledge. It is plausible that suboptimal feeding practices have deep roots due to poorly designed and ineffective educational packages on breastfeeding. Coupled with this are several age-long myths that fuel the poor breastfeeding rates. In the event that this persists, a decrease in ideal breastfeeding practice among Nigerian mothers is anticipated. Nevertheless, this differs from findings in a study where breastfeeding knowledge was high and most of the respondents understood what exclusive breastfeeding was. Additionally, the percentage of respondents with good breastfeeding knowledge was similar to that of Korean undergraduates which was far from average, as well as a study in Nigeria among female students of School of Health Technology, Ilesha.

Adolescence howbeit early, the choice to breastfeed is made in this stage and it is exceptionally reliant on the breastfeeding information recieved. The greater part of the respondents in this study concurred that water ought to be introduced to infants before 6 months, and they were of the view that breastfeeding in the general population is humiliating; these were corroborated by other studies.[14,19]

Furthermore, reasons for favouring breastfeeding included mother-infant bonding, breastfed babies are healthier than formula-fed babies, breast milk is cheaper than formula and benefits of EBF last till adulthood, which are closely related with the findings in the study. Also, it was revealed that more of respondents had positive attitude toward exclusive breastfeeding. This is complemented by a study but in contrast to the study in Rwanda, Ethiopia as well as a study Nigeria with lower percentages.[20,21,22]

A larger part of this study’s respondents planned to breastfeed later. This is not in congruity with the investigation in Ibadan where less than one-third of the respondents know all that is required to breastfeed their future children.

Although an investigation on intention to breastfeed found that an immense number of the respondents intend to start breastfeeding within the first hour of birth, this current study found otherwise. These results from Nigeria are not in line with the WHO recommendation.

Finally, age played a significant role in respondents’ intention to breastfeed as younger respondents had poorer intention. In respect with religion, Christians had better intention to breastfeed. The fathers’ education and mothers’ education were both instrumental in a good intention to breastfeed. The higher the educational attainments, the better the intention. All of these give clarity on selected areas to target and develop effective educational programmes for adolescents. It is important to identify the potential in identifying adolescents, and work with them to ensure they have all the facts, using health promotion strategies so that they can make an informed decision on breastfeeding by adulthood. For example, fathers’ support toward exclusive breastfeeding (EBF) is becoming recognized as a critical entity for successful EBF in a study that identified the significant effect of a breastfeeding programme on intention. It is also vital to include all other entities essential in achieving optimal breastfeeding.

Limitations

The limitation of this study is that the sample size was not large enough, which reflected in the wider confidence interval. Therefore, further study should be conducted with a larger sample to produce a better estimate of the population parameter, when all other factors are equal.

Conclusion

Majority of adolescents demonstrated poor intention to breastfeeding. The EBF intention was influenced by multiple factors and should be considered in determining the effectiveness of interventions targeting this practice. Therefore, coherent breastfeeding education interventions that commence from adolescence to promote the EBF practice by adulthood are urgently needed to confer the numerous EBF benefits.