Determinants of suboptimal breastfeeding practices in Nigeria: evidence from the 2008 demographic and health survey

Optimal breastfeeding rates (early initiation of breastfeeding and exclusive breastfeeding) were very low (38% and 13% respectively), indicating that most children under-6 months were given other foods or liquids in addition to breast milk. The prevalence of bottle-feeding and predominant breastfeeding were high (15.3% and 48.1% respectively) in children aged 0–23 months and 0–5 months, respectively – a period of development when optimal breastfeeding is most important for child health and development [2,39]. Additionally, this study found that lower maternal age and education, lower household wealth, lower frequency of antenatal visits, and caesarean delivery at a health facility were associated with feeding behaviours that did not meet recommended standards. There was also substantial geopolitical variability in breastfeeding patterns, with relatively lower prevalence in the less urbanised jurisdictions of Nigeria (North East and North West) compared to other regions.

There are a number of methodological limitations that need to be considered in interpreting findings from the current study. Firstly, breastfeeding indicators were based on self-report. This is a potential source of measurement bias in the outcome, where women may incorrectly recall how the child was fed during the periods referred to by the survey questions. Similarly, misclassification in selected study variables may also be present, for example over- or under-estimation of the number of health service visits. Selection bias is less likely to affect observed findings, due to the nationally representative sampling frame of the survey and high response rate. Selected samples were drawn from the 2006 national census frame yielding 98% response rate without significant differences between urban and rural areas. Finally, the findings are based on cross-sectional data, so it is difficult to ascribe temporality between putative exposures and outcomes. However, implied temporal associations are more logically sustainable for exposures that are categorical and fixed, and established early in life around seminal events, such as educational achievement, and some reproductive factors such as number of children and the date of birth of a child.

The findings showed that mid-reproductive age of the mother (25–34 years) was associated with exclusive breastfeeding compared to younger mothers, signifying that younger mothers may be inexperienced in conventional infant feeding practices and may be more likely to engage in suboptimal feeding practices. Similar studies in Nigeria and Canada reported lower maternal age as a significant factor for non-EBF [17,25,26,40]. A recent study in Nigeria found that counseling at the health facility was an important strategy for promoting exclusive breastfeeding practice in women [26]. Similarly, findings from an international literature review found that using breastfeeding peer support strategy was effective in ensuring exclusive breastfeeding among mothers [41]. Accordingly, these approaches could be employed in Nigeria to improve the uptake of exclusive breastfeeding among younger mothers in communities.

High maternal education was associated with a greater likelihood of exclusive breastfeeding compared to mothers with no education. The association with education became stronger after controlling for household wealth suggesting that it was not a wealth effect. Nonetheless, previous studies from developing countries reported that women of higher socio-economic status (SES) groups may be more likely to have better access and respond to health promotion messages (including infant feeding messages) compared to women of lower SES groups [42-44]. This finding is consistent with previous studies in Nigeria and Tanzania that reported low maternal education as a major determinant for non-exclusive breastfeeding [15,17,19,23,24]. Similarly, the study also found an association between mothers who had at least a primary level of education and predominant breastfeeding compared to mothers with no schooling, indicating the crucial role of mother’s education on infant nutrition and development. Studies have shown that primary education is the basic threshold required to benefit from health information, and it provides marginalised groups – particularly women – the self-confidence desired to act on health information [45]. In Nigeria, previous studies found that women with no schooling had limited knowledge and attitude towards optimal breastfeeding practices [24,27]. Therefore, continuous implementation and sustainability of the MDG project in this context is crucial to improving breastfeeding practices of Nigerian women.

Previous Nigerian studies reported various reasons for why women of low SES groups do not exclusively breastfeed their babies including, that EBF is demanding [46], a perceived notion that the child continued to be hungry after breastfeeding [27,47], lack of family support [27,46]; and women in private or public employment engaged in non-EBF due to existence of workplace barriers that do not support appropriate breastfeeding practices [48,49]. A recent study in regional Nigeria found that mothers who had contacts with a health facility received information about optimal breastfeeding practices [25]. Thus, national health policies and programs that encourage mothers of low SES groups to access health facility are recommended to improve breastfeeding patterns in Nigerian women.

Studies from Ghana and Nigeria reported that mothers who used conventional health services engaged in better breastfeeding practices [13,50]. However, in the present study, mothers who made frequent antenatal visits (ANC), predominantly breastfed and bottle-fed their babies compared to mothers who made no ANC visits. Access to a health facility provides an opportunity to obtain and respond to health promotion messages, and ANC visit present an important opportunity for implementation of appropriate infant feeding intervention strategies to promote optimal breastfeeding behaviours. Findings from this study, however, suggest that relevant messages about breastfeeding may not have been communicated effectively to mothers by antenatal staff. Similarly, mothers may have received the right messages, but socio-cultural beliefs such as a perceived notion that water is needed by the baby after breastfeeding, lack of family support [27] or pressure to resume work [28,48] influenced their decision to predominantly breastfeed or bottle-feed. For example, in many Nigerian communities, new mothers do not have the autonomy to exclusively make household decisions regarding infant and young child feeding. These decisions are often made by the father or by the grandmother (paternal or maternal) [51] acknowledging that Nigerian grandmothers usually provide significant support to nursing mothers [27], and most grandmothers are knowledgeable in infant feeding practices but these skills are often based on traditional belief systems [52]. Based on their role, they can play a large part in influencing mother’s decision to predominantly breastfeed or bottle-feed [53], and this may be an additional reason for why mothers in Nigeria, engage in suboptimal feeding practices.

Although, the association between employment status and key breastfeeding indicators was not apparent in this study, recent studies in Nigeria found that employed mothers predominantly breastfeed and bottle-feed their babies due to pressure to resume work [15,28,48], and thus, dedicate less time to optimal breastfeeding practices. Employed mothers in private or public organisations – more likely to be educated and work under rigid time schedules – may not have flexible time to engage in optimal breastfeeding practices compared to unemployed or self-employed mothers, and it appears that organisational employment may repudiate the benefits of higher education on optimal breastfeeding patterns. A response to this impediment in Nigeria has been a regional government initiative, which recently announced 10-days paid parental leave for male public servants and extended paid maternity leave for female public officers from three to six months, with the promotion of exclusive breastfeeding being part of the rationale for this intervention [54]. National policies that support nursing mothers in work environments such as provision of crèches, paid parental leave and extended paid maternal leave including strengthening of the International code of Marketing of Breast-milk Substitutes in Nigeria are proposed to improve breastfeeding outcomes.

Early initiation of breastfeeding is essential to the health and development of the infant [2,3] and its delay may be a significant risk factor for infant mortality [39]. In the present study, a birth interval of more than 24 months was associated with early initiation of breastfeeding, suggesting that family planning can promote breastfeeding practices. In Nigeria, mothers with no schooling are more likely to deliver at home compared to educated mothers, and home delivery remains an impediment to early initiation of breastfeeding [29]. Mothers with at least a primary education engaged in early initiation of breastfeeding compared to mothers with no schooling, suggesting that educated mothers were more likely to have their babies at a health facility that would require delivery supervision by a health professional [29]. Studies from Nigeria and Australia found that father’s education played an important role in optimum breastfeeding [55,56], and in the present study, babies of educated fathers were breastfed, within the first hour of birth. However, mothers who delivered their babies at a health facility by caesarean section, delayed initiation of breastfeeding compared to mothers who delivered vaginally at home without skilled personnel supervision. In the study, frequent ANC visit was associated with early initiation of breastfeeding. Similar studies done in Nigeria, Tanzania, Guatemala, Ghana and Pakistan identified mother’s education, ANC visits, mode and place of delivery as significant determinants for early initiation of breastfeeding [17,19,28,37,38,57].

Consistent with this finding, some studies done in Ghana and Nigeria [28,38], and a report from an international review [58] suggested that caesarean section and peri-natal care remained important impediments to early initiation of breastfeeding, where babies were usually handed over to the paediatrician or the paediatric nurse for care while the mother was still in post-operative or peri-natal care [28,38]. Further training of health professionals is required to ensure the wider benefits of focused antenatal care (ANC) (a four-visit ANC model) and baby friendly hospital initiatives (BFHI). However, in many developing countries like Nigeria, most deliveries occur at home, and those that deliver in the hospital return to their homes and communities for postnatal care of their babies [59]. Thus, baby friendly community initiatives (BFCI), which are community-based approaches to protect, promote and support optimal breastfeeding practices are also proposed as an adjunct to health service based initiatives [59].

Mothers from wealthier households with higher educational achievement were more likely to engage in bottle-feeding practices compared to mothers from poorer households with lower educational achievement respectively, suggesting that higher socio-economic status women – more likely to be employed in formal environments [60-62] – have the material resources to purchase formula foods. Similarly, babies of educated fathers received foods mainly from a bottle compared to babies whose fathers had no schooling, indicating that socio-cultural perceptions about breastfeeding have also engendered a preference for bottle feeding [49]. These findings were similar to those previously documented in Guatemala and India, where an association between maternal education, household wealth and bottle feeding was also reported [57,63].

Nigerian data from the Millennium Development Goals (MDGs) performance tracking survey showed that the literacy rate among women from Southern Nigeria (89% - 92%) was higher compared to women from Northern Nigeria (30% - 66%), and women from the Southern zones were more likely to transit to higher educational levels [64]. Similarly, women from Southern geopolitical regions – more educated and wealthier zones [65] – of Nigeria had better access to health care services compared to women from Northern Nigeria, and are more likely to be employed [64]. These observed differences may play an important role in the geopolitical variability in infant feeding practices identified in the current study.