2.0. Introduction
This chapter reviews the empirical literature relating to breastfeeding attitudes, Demographic factors, and breastfeeding knowledge. The study objectives guide the review. A summary of the reviewed literature and gaps identified in the existing literature are also highlighted. Also contained in the chapter are the theoretical and conceptual frameworks underpinning the study?
2.1 Breastfeeding Practices
Breast feeding practices are the practices to be followed in breastfeeding a baby (Beckerman et al., 2020). Human milk is preferred for all infants, including premature and sick newborns, with rare exceptions (Zhu & Dingess, 2019).Global Monitoring indicates that only 39% of all infants worldwide are exclusively breastfed(Gupta et al., 2019). The overall rate of exclusive breastfeeding for at least six months is only 37% in the developing world and 39% in the least developed countries(WHO, 2018).
According to Ahmed et al. (2018), over 10 million children under five die each year in sub-Saharan Africa and South Asia. Most of these deaths (41%) occur in Sub-Saharan Africa and 34% in South Asia due to poor breastfeeding practices(Walters et al., 2019). A significant cause of death in infants and young children is inadequate breastfeeding practices combined with high levels of disease (Aguayo,2017). Ratovoson et al. (2020) found that one in ten children die in the first year of life, and one in six dies before five years in Madagascar. In South Africa, 10% of children 0-3 months were exclusively breastfed, and 2% of children 4-6 months were exclusively breastfed(Chakona,2020). A study in Uganda on low adherence to exclusive breastfeeding showed that 7% and 0% practiced exclusive breastfeeding by three and six months, respectively (Dukuzumuremyi et al., 2020).
In Kenya, IYCF practices are sub-optimal. The Kenya Demographic Health Survey(KDHS, 2014) report indicated that exclusive breastfeeding is not common with most mothers as only32% of infants under six months of age are exclusively breastfed(KDHS, 2014). According to KDHS (2014), the median duration of exclusive breastfeeding stands at 0.5 months in Nairobi compared to 0.6 months in KDHS (2010). A study conducted in Kathonzweni Division, Makueni District, indicated poor exclusive breastfeeding practice, with 50.6% of children receiving complementary feeds at three months of age (Galgallo,2017).
The rate of exclusive breastfeeding among children less than six months in sub-Saharan Africa was 35% in 2017 (Asare et al., 2018). According to Olufunlayo et al. (2019), only 39 percent of children under six months of age in the developing world, including Africa, are exclusively breastfed, and just 58 percent of 20-23-month-olds benefit from the practice of continued breastfeeding. A growing number of countries demonstrate that significant and rapid progress is possible, with 25 countries showing increases of 20 percentage points or more (WHO, 2018).In some regions, the rates of formula feeding are very high, even though many women appear to know the benefits of breastfeeding. Women in these regions appear resistant to changing their infant feeding methods and often rationalizing their formula-feed decisions (Neves, et al., 2021). In Kenya, 10% of children are on formula (KDHS, 2014).
The HIV pandemic resulted in increased formula use in Africa to prevent mother-to-child HIV transmission(Gummed, Moyo et al., 2017). The provision of free commercial infant formula through the public health system may also reinforce the common practice of mixed feeding in the general population (Trafford et al., 2020).Thus, the significant problems are the societal and commercial pressure to stop breastfeeding, including aggressive marketing and promotion by formula producers. Formula feeding is also widespread in Africa (Trafford et al., 2020).
2.2 Demographic Factors Associated with breastfeeding practices
Demographic characteristics of both the mother and the infant may have a bearing on breastfeeding practices. In a study carried out in Nyando, Kenya by Ogada (2014) infant sex was significantly associated with exclusive breastfeeding. The age of the infant has also been significantly associated with exclusive breastfeeding. In the study carried out in Nyando, the rate of exclusive breastfeeding decreased with an increase in infant age. Similar observations were made in the Nairobi study, where the age of infants was associated with exclusive breastfeeding (Kimani Murage et al., 2017). These findings suggested that the younger the child the higher the chances of being exclusively breastfed.
Maternal age has also been associated with exclusive breastfeeding. In a study carried out in Rural Kenya, maternal age was associated with breastfeeding practices as mothers of lower age did not practice exclusive breastfeeding (Talbert et al., 2020). Additionally, a study conducted by Mohamed et al. (2020) in the North-Eastern region of Kenya indicated that older mothers were more likely to breastfeed. Conversely, younger mothers were more likely to practice exclusive breastfeeding, as Mututho et al. (2017)reported in a study conducted in Nairobi.
Other studies have also linked marital status with breastfeeding practices. Marital status was associated with exclusive breastfeeding practices among lactating mothers in Ethiopia's study conducted by Adugna et al. (2017). Moreover, in Nairobi, one of the predictors of the early introduction of complementary foods reported was the mother’s marital status(Mututho et al., 2017).
Gravidity and parity have also been associated with breastfeeding practices. Gravidity is defined as the total number of pregnancies, regardless of the outcome. On the other hand, parity is the total number of pregnancies carried over the threshold of viability(Hughes, 2018). In a study conducted by Reed et al. (2020), multiparous mothers were more likely to practice exclusive breastfeeding. Similarly, a study conducted by Alzaheb (2017) in Saudi Arabia also affirmed the tendency of primiparous mothers to introduce their infants to complementary feeds. Such studies also link multigravida women with exclusive breastfeeding.
In other studies, Ethnicity and religion have been found to influence breastfeeding practices. In a study conducted by Fombong et al. (2016), mothers of various religious persuasions were less exclusively breastfeeding than their atheist counterparts. Other studies have considered religion a component of culture and thus argued for cultural influence on breastfeeding practices. For instance, Dorrance Hall et al. (2020) concluded that cultural beliefs and norms have a powerful influence on human nutrition and are arguably the most vital determinant of breastfeeding practices.
2.3 Knowledge and breastfeeding practices
Knowledge refers to familiarity, awareness, or understanding of a phenomenon. Such may include facts about a phenomenon or propositional knowledge, skills or procedural knowledge, as well as knowledge about an object or acquaintance knowledge(Muller & Young, 2019). The knowledge one has on breastfeeding may influence breastfeeding practices. A study conducted by Wallenborn et al. (2017) established that most mothers (91.7% ) did not exclusively breastfeed the recommended duration, and one in five (21.4%) did not know current breastfeeding recommendations. The Wallenborn et al. (2017) study further established that women without knowledge of exclusive breastfeeding recommendations had a lower probability of breastfeeding than women with knowledge of breastfeeding recommendations. Similarly, a study conducted by Ihudiebube-Splendor et al. (2019) established that more than half (58.7%) of primiparous mothers had inadequate knowledge of EBF, and only 62.7% had the intention to breastfeed for 4–6 months exclusively.
Such studies, therefore, provide evidence of the association between knowledge and breastfeeding practices. In a survey done in Somalia, it was found that knowledge, attitude, and practices (KAP) on breastfeeding are mainly controlled by culture through maternal grandmothers and other older women in the community and are generally unsatisfactory(Gee et al., 2019). Most children are put on breast 2-3 days after delivery, and the colostrum is not fed to the children by the majority as it is considered heavy, thick, coarse, dirty, and toxic to their health. Pregnancy also was found to contraindicate breastfeeding, as the milk is thought to be red and poisonous to the breastfeeding infant. It was also thought to affect the unborn infant by making it weak. Breastfeeding is, however, acceptable to all mothers, and almost all children breastfeed on demand. Lack of knowledge, inappropriate beliefs and very close birth spacing are significant obstacles to successful breastfeeding.
Literature has confirmed that breastfeeding knowledge positively affects the success of exclusive breastfeeding(Colombo et al., 2018; Keles, 2021). In a clinical trial performed in Brazil to assess the knowledge of mothers and fathers about breastfeeding and its relationship to the frequency of breastfeeding, they found that the mothers with the highest level of knowledge had a 6.5 times higher chance of exclusively breastfeeding to the end of the 3rd months and 1.97 times higher chance of continuing breastfeeding to six months compared to the other mothers. In the same regard, step three of the ten steps to successful breastfeeding advocates for mothers’ provision with information about the benefits of breastfeeding, as mothers` knowledge can influence their breastfeeding intention, although it might not necessarily have much effect by itself.
In Nigeria, it was found that 71.35 of the mothers had good knowledge of breastfeeding(Ogbonna, 2014). In that study, 46% of mothers reported that breastfeeding is a contraceptive method, while 76% knew that it promotes mother, baby bond, and 70% knew that it maintains mothers` weight(Joseph & Earland, 2019).
2.4 Attitude towards exclusive breastfeeding
Various studies have been conducted on mothers’ attitudes towards breastfeeding and formula use and how they affect their infant feeding choices. In a study by Russell et al. (2021), breastfeeding in public was also cited as a significant influence on their mother’s decision to formula-feed, though this may not apply in our African context (Atkinson et al., 2021). The belief that breastfeeding is not convenient for a woman’s lifestyle was also described in the literature (Lyons et al., 2021). In regions where formula feeding is predominant, health care providers may assist in initiating the conversation about infant feeding choice early in pregnancy in a non-threatening, non-judgmental manner(Lyons et al., 2021). Pre-natal visits provide opportunities to share information to facilitate an informed decision, explore the mother’s concerns and beliefs and to link with community-based support programs (Melwani et al., 2021). The convenience associated with formula feeding is a belief that was held by the women in the Canadian qualitative study by Pemo et al. (2020). Convenience is inherently linked to the embarrassment of breastfeeding in public. In the Canadian study, women suggest that it is more convenient to formula-feed their infants because it is unnecessary to go to a private room or cover up when feeding in public (Whiley et al., 2020).
Community beliefs concerning colostrum have been shown to influence exclusive breastfeeding. According to a study conducted by Mututho et al. (2017) in Kenya, the belief that colostrum is harmful to the infant prompted mothers to give pre-lacteal feeds to infants since they believed that fresh milk is produced from the third day. The Mututho et al. (2017) also reported that giving water and sugar/glucose and salt or a commercially prepared mixture of water (gripe water) to protect the baby from stomach problems is a common belief not only among mothers but also among community health or social workers that affects the duration of exclusive breastfeeding. Additionally, in a qualitative study conducted in Korogocho and Viwandani slums, socio-cultural beliefs and practices resulted to suboptimal breastfeeding. Some of the mothers considered colostrum as dirty; others believed that breastfeeding while engaging in extra marital affairs was a bad omen or a curse; fear of the evil eye (malevolent glare that is believed to be a curse associated with witchcraft) when breastfeeding in public while others associated breastfeeding with sagging breasts(Kaman Murage et al., 2015). On the other hand, some believed that breastfeeding was associated with intellectual development and good health of the infant. In a study conducted in Kyushu by Mbuka et al. (2016), maternal knowledge of traditional and cultural practices surrounding exclusive breastfeeding was associated with exclusive breastfeeding practices.
A study conducted in Mere reported that cultural infant feeding practices such as pre-and post-lacteal feeds were barriers to exclusive breastfeeding(Malaria & Kimiywe, 2020). The findings above demonstrate that our socio-cultural practices and beliefs play a significant role in determining infant and young child feeding practices. Psychosocial factors and social support several studies have cited psychosocial and social support as important factors for helping mothers initiate and maintain exclusive breastfeeding for the recommended six months(Alianmoghaddam,et,al,2018; Hijazi et al., 2021). Some mothers have been noted to avoid exclusive breastfeeding since they associate it with HIV status. This is mainly because counseling emphasizes strict exclusive breastfeeding followed by rapid weaning for HIV-positive mothers.
Maternal perception about breast milk influences exclusive breastfeeding practices. According to Mututho et al. (2017), the main reason for introducing complementary food early was the mother’s perception of insufficient breast milk. This finding was in line with another study conducted by Kossou et al. (2021) which showed that the perceived lack of sufficient breast milk was the main reason for early breastfeeding cessation or early introduction of complementary foods. Mother’s perceptions of the impact of EBF on the mother’s health, physical appearance, and ability to engage in other activities were shown to consistently have, the strongest relationship with premature EBF cessation among mothers (Constance A Gewa & Joan Chepkemboi, 2016). Addressing these beliefs has the potential to contribute to more effective EBF promotion efforts. Further, the babies’ perceived ill health made caregivers use various foods and drink other than breast milk for feeding the infants. Stomachache, abdominal colic, diarrhea, and fever were among the most frequently recognized health problems in children.
2.5. Summary and gaps in the literature review
This section summarizes the literature reviewed, noting what is known, what is unknown, and the gaps in knowledge. In addition, it identifies the gap in knowledge and any additional knowledge the current study seeks to address. The literature reviewed shows that breastfeeding rates are still low among women in various setups globally, in Africa and Kenya. Formula feeding is widespread both in Africa and other parts of the world despite the varied reasons for its use in different communities of the world. Most of the recent studies on the socioeconomic factors and attitudes influencing breastfeeding practices are from outside Africa and thus need for more studies in Kenya on the factors. Literature reviewed show that both low and high economic statuses are associated with decreased breastfeeding practices and attitudes in different communities of the world. Literature reveals that the attitude or choice to breastfeed by mothers, is influenced by a complex web of factors that include the socioeconomic determinants of health such as marital status, level of education and income, access to prenatal care, and social supports that include family, partner, the health system well. Some studies suggest that positive maternal attitudes and mothers’ intention not to breastfeed and use formula is learned from partners. In the studies reviewed, some agree on feeding as influenced by perceptions, attitudes, or influence of significant others, while others do not agree.
Studies reviewed show that the age of the mother, level of education, and social-economic status influence feeding among communities while others do not agree. Studies on knowledge and practices associated with mothers’ attitude are not many in Africa and Kenya, as most concentrated on the prevalence of breastfeeding. Studies on determinants specific to knowledge and practices associated with mothers’ attitude in Kamukunji, have not been done, hence the gap this study aims to fill.
2.6. Theoretical Framework
The study is guided by the theory of reasoned action (Ajzen & Fishbein, 1975). The theory of reasoned action or planned behavior (TRA), suggests that a person’s behavioral intention depends on the person’s attitude about the behavior and subjective norms (BI = A + SN). If a person intends to do a behavior, they will likely do it. The theory uses three constructs: behavioral intention (BI), attitude (A), and subjective norm (SN). Subjective norm is a combination of perceived expectations from relevant individuals or groups and intentions to comply with these expectations. In other words, “the person’s perception that most people who are important to him or her think he should or should not perform the behavior in question(Janzen & Fishbein, 1975).This theory is based on the assumption that the mother’s intention not to breastfeed and instead use formula is based on her attitudes, knowledge, and other personal factors. The constructs of TRA are used to explain behavioral intention, i.e., attitudes and socioeconomic factors influence mothers’ attitudes to breastfeeding. This is as presented in figure 1., below,
2.7. Operational framework
Figure 2: below shows the operational framework. The outcome variable will be breastfeeding practices, and the independent variables are mothers’ attitudes, knowledge and socio-demographic characteristics.