Knowledge, Attitude, and Practice Towards Exclusive Breastfeeding and Associated Factors Among Adolescent Mothers in Nyagatare District, Rwanda

doi:10.21203/rs.3.rs-4622583/v1

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Research Article

Knowledge, Attitude, and Practice Towards Exclusive Breastfeeding and Associated Factors Among Adolescent Mothers in Nyagatare District, Rwanda

https://doi.org/10.21203/rs.3.rs-4622583/v1

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Background: Breastmilk contains necessary nutrients that an infant needs to grow healthy and protects an infant from infectious and chronic diseases. Breastfeeding reduces the risk of ovarian and breast cancer in mothers. Breastmilk is safe, affordable, and healthy, and the WHO recommends that an infant receive exclusive breasting for the first half year of life to reduce malnutrition and child mortality and improve maternal health.

Methods: This cross-sectional study aimed to assess the knowledge, attitudes, and practices of adolescent mothers toward exclusive breastfeeding among 194 adolescent mothers in the Nyagatare district of Eastern Province.

Results: The results indicated that 85.6% of adolescent mothers understood exclusive breastfeeding. A total of 78.9% of the mothers reported having a positive attitude; however, only 27.3% of the adolescent mothers reported exclusively breastfeeding. Higher levels of education had significant effects, with adolescent mothers having primary education (AOR = 1.161, 95% CI = 1.721 - 2.319, p = 0.009), secondary education (AOR = 3.056, 95% CI = 2.006 - 5.542, p = 0.013) and positive attitudes (AOR = 5.702, 95% CI = 1.633 - 19.91, p = 0.006) Having occupation (AOR = 2.041, 95% CI = 0.556 - 7.497, p = 0.282) Urban residence (AOR = 1.622, 95% CI = 1.038 - 3.089, p = 0.007) exhibiting increased odds of practicing exclusive breastfeeding compared to those with no formal education. However, having no desire for a previous pregnancy (AOR = 0.204, 95% CI = 0.051 - 0.817, p = 0.025) and having only one (AOR = 0.418, 95% CI = 0.037 - 0.792, p = 0.043) significantly decreased the odds of exclusive breastfeeding.

Conclusion: Breastfeeding offers vital benefits, yet practices remain limited. Enhancing exclusive breastfeeding requires targeted interventions and support.

Exclusive breastfeeding

adolescent mothers

Rwanda

Breastfeeding a newborn baby exclusively with breastmilk from birth to 6 months of life sustains the health of the child and the mother, and newborns obtain all necessary nutrients they need and are also protected against certain illnesses and diseases, such as pneumonia and diarrhea; mothers who exclusively breastfeed their babies are less likely to have breast and ovarian cancer and high blood pressure [1].

The status of exclusive breastfeeding knowledge, attitudes, and practices among mothers presents a multifaceted picture. While significant progress has been made in raising awareness about the benefits of exclusive breastfeeding, challenges persist in translating knowledge into action. According to recent statistics, only a fraction of infants worldwide, approximately 41%, are exclusively breastfed during the first six months of life, as recommended by the World Health Organization [2]. This indicates a substantial gap between awareness and practice. Furthermore, disparities exist across regions and socioeconomic groups, with higher rates of exclusive breastfeeding observed in low-income countries than in higher-income nations.

The global rate of exclusive breastfeeding for improving the health of newborns remains unclear, as only 38% of newborns are exclusively breastfed in the first six months of life (Ejie et al., 2021). Sub-Saharan Africa is renowned for high rates of infant mortality (41.6 deaths per 1000 live births); however, only 33% of infants are exclusively breastfed (Borra et al., 2012). Rwanda had the highest percentage of children exclusively breastfed for the first 6 months of life (87%) in 2015, which slightly declined to 81% in 2020 (RDHS, 2020).

(World Health Organization, 2019) estimated approximately 823,000 underfive deaths and 200,000 deaths from breast cancer because of poor breastfeeding practices and approximately 595 379 childhood deaths from diarrhea and pneumonia attributed to poor breastfeeding practices. A total of 98243 deaths from breast and ovarian cancers resulted from poor breastfeeding practices (Walters et al., 2019).

The WHO (2019) recommended that for the first six months of life, a newborn baby should be fed only breastmilk without other solids, water, or other liquids, which is called exclusive breastfeeding. Breastmilk is clean, safe, and free for every family regardless of their social and economic status, and every woman can easily learn to breastfeed a baby and can do so anytime and anywhere (Hunegnaw et al., 2017).

Approximately 21 million (15%) adolescent girls become pregnant each year; of these, approximately 12 million result in childbirth. Approximately 18.8% of global adolescent pregnancies occur in Africa, 19.3% of which are in Sub-Saharan Africa, and 21.5% of which occur in eastern Africa, where Rwanda is located; half of these pregnancies are unwanted [3], and over 78000 babies were born to first-time adolescent mothers in Rwanda in four years (2016–2019) [4].

Exclusive breastfeeding has a healthy effect on the cognitive development of a child, well-breastfed babies tend to perform better at school [5], breastmilk is a rich source of fatty acids essential for the development of the infant’s brain, optimal breastfeeding reduces stunting among children [6], and the longer a child is breastfed, the more health benefits are received [1]. Exclusive breastfeeding investment contributes to poverty reduction as the first goal of sustainable development, and USD $35 was estimated to return for a dollar invested by a country in sensitizing breastfeeding policy. Annually, USD $302 billion, equivalent to 0.5% of gross national income, is lost due to inadequate breastfeeding rates globally.

Studies conducted on exclusive breastfeeding among adolescent mothers revealed positive attitudes and practices related to the early initiation of exclusive breastfeeding (> 70%); however, approximately half of these attitudes and practices may stop within the first month, and only 20% continue to exclusively breastfeed for up to the recommended 6 months [7].

Poor families, lack of social support, lack of knowledge about breastfeeding and feeling embarrassed about feeding in public were mentioned as barriers to breastfeeding. Adolescent mothers were observed to face most of the barriers to breastfeeding and were disproportionally less likely to breastfeed their children [8].

The 6th demographic and health survey conducted in Rwanda [9] showed that during five years (2015–2020), the exclusive breastfeeding rate declined from 87–81% among women of all reproductive ages (15–49), and little is known about the trend of exclusive breastfeeding among adolescent mothers in Rwanda. A study conducted by [10] indicated that approximately 97.4% of adolescent mothers adhered to early initiation of EBF in the first life of a child; however, only 20% continued to exclusively breastfeed their babies within the first six months, as recommended by the WHO and UNICEF. This gradual decrease in EBF practices among adolescent mothers was linked to poor physical and social support from families, undesired pregnancy, and a lack of knowledge on maternal role. The studies that have been conducted on breastfeeding and associated factors have focused on women in general, and little is known about adolescent populations who may have different perceptions; moreover, these studies have reported disproportionate low breastfeeding rates among adolescent mothers. This gap that our study intends to address is to explore in depth the knowledge, attitudes, and practices of adolescent mothers toward exclusive breastfeeding. Therefore, this study aimed to assess the knowledge of adolescent mothers regarding exclusive breastfeeding and their attitudes and practices in the Nyagatare district. The findings will contribute to improving EBF practices among adolescent mothers to sustain the healthy growth of a child and health benefits for the mother.

Study design, setting and participants.

Research design refers to the framework of methods to be integrated in the study for the purpose of answering research problems, and the research design reveals the techniques for data collection and analysis [11]. This study was cross-sectional and is a type of study in which the investigators measured both exposures and outcomes at a single point in time [12]. This study assessed the knowledge, attitudes, and practices related to exclusive breastfeeding among adolescent mothers in the Nyagatare district. The research data were collected in June 2023. The most recent RDHS survey, which was conducted in 2019–2020, was the sixth survey, following those in 1992, 2000, 2005, 2010, and 2014–15.

Data collection instrument and procedures

The data were collected using interviewer-administered questionnaires. This data collection tool was developed based on the objectives of the study and by consulting the related literature [13]. The variables included are in line with the research objective. The questionnaire consists of closed questions that suggest options of answers for a respondent to choose from. To ensure that the variables reflect the true meaning and objective of the research, the Kinyarwanda questionnaire was translated with the support of Kinyarwanda Lecturer and students in the Department of Linguistics from the University of Rwanda.

Data Analysis

The collected data were entered and analyzed using SPSS-21. After ensuring the cleanliness of the data, descriptive analysis was used to evaluate the knowledge, attitudes, and practices related to exclusive breastfeeding among adolescent mothers, and bivariate analysis was used to analyze the associations between independent variables such as sociodemographic variables, knowledge, attitudes and practices factors associated with exclusive breastfeeding. The significant variables were regressed using binary logistic regression to predict exclusive breastfeeding practices. To assess the attitudes of adolescent mothers toward breastfeeding. A Likert scale was used. The Likert scale is a psychometric tool used to measure people's attitudes, opinions, and perceptions toward a particular topic. It consists of a series of statements or questions that respondents are asked to rate based on their level of agreement or disagreement with the statement [14]. In this study, the Likert scale consisted of 5 scales, which included 1 = Strongly Agree, 2 = Agree, 3 = Unsure, 4 = Disagree and 5 = Strongly Disagree. The use of Likert scales enables researchers to make comparisons between different groups and draw meaningful conclusions from the data. While assessing the practice level, the following scores were used. Starting breastfeeding within the first hour was assigned a score of 4. Breastmilk as the first feed was assigned a score of 4. Breastfeeding on demand was assigned a score of 4. The cumulative score for each participant was calculated by summing the scores of their responses. This cumulative score represented the overall practice level of breastfeeding, with higher scores indicating better adherence to recommended practices. For the knowledge assessment, the score for good answers was 1, while the scores for both wrong answers and noncorrect answers were 0. The maximum attainable total score was 10, and the minimum was 0. A percentage score was generated and classified as inadequate knowledge (˂50%), moderate knowledge (50–69%), or adequate knowledge (≥ 70%). The results are presented in tables and appropriate graphs [15].

Ethical consideration

Before the research was conducted, a review and approval from the Mount Kenya University Research Ethics Committee were granted, and an introduction letter from the postgraduate school helped the researcher obtain the recommendation letter from the Nyagatare district for conducting the study. Participants were first informed of the study objectives, the privacy of their information and the freedom to withdraw at any time they wanted. The participants read and signed the consent form prior to answering the questions. The questionnaire was developed in a way that is harmless and involves no discrimination, harassment, or emotional trauma to respondents. The data will be confidentially stored in SPSS software, and only the researcher and the school of public health from Mount Kenya University will be given access to the collected data, and the data will be stored for 5 years.

The analyzed data were collected from 194 participants using interviewer-administered questionnaires from June to July 2023. Descriptive analysis was used to evaluate knowledge, attitudes, and practices regarding breastfeeding. Logistic regression was used to analyze influencing factors, including socioeconomic factors associated with breastfeeding practices. This study highlights the importance of sustaining exclusive breastfeeding and provides valuable insights to guide policy makers in developing targeted interventions to improve breastfeeding practices, reduce malnutrition and child mortality, and enhance maternal health in the region.

Demographic characteristics of the respondents

The table presents the demographic characteristics of the participants in the study. A total of 194 adolescent mothers from the Nyagatare district were included, with the majority falling within the age range of 18 to 19 years (69.1%), while 30.9% were aged 15 to 17 years. Regarding education levels, the participants exhibited varying degrees of educational attainment. The highest proportion had primary education (37.6%), followed by those with no formal education (19.6%) and those with secondary education (16%). A smaller percentage had pursued higher education, with 2.1% attending college/university and 24.7% enrolled in technical and vocational education and training (TVET/VTC) programs.

Occupational diversity was evident among the adolescent mothers, with casual workers comprising the largest group (27.8%), followed by farmers (16.5%) and those who were not employed (25.8%). Some were self-employed (14.4%), were private employees (6.2%), and were students (9.3%). The UBUDEHE category, a socioeconomic classification system in Rwanda, showed that most of the participants fell under Category III (72.2%), while Category II accounted for 25.8% and Category I accounted for a small proportion (2.1%). The income distribution indicated that a significant majority had a monthly income below 50,000 Frw (93.8%), while a minority reported earning between 50,000 Frw and 100,000 Frw (6.2%). In terms of marital status, the majority of the adolescent mothers were single (77.8%), while a negligible percentage were married (0.5%) or living together (21.6%).

Religiously, the participants showed diversity, with the highest proportion being Catholic (33%), followed by those who were not religious (12.9%), those who were protestants (19.6%), Muslims (12.4%), and others (22.2%). Geographically, the study captured both urban and rural representations, with 41.8% of participants residing in urban areas and 58.2% residing in rural areas.

Concerning the source of information, it is evident that health facilities played a significant role, as 57.2% of the adolescent mothers obtained information about breastfeeding practices from these facilities. Community health workers were also an essential source, with 12.9% of participants seeking information from them. Interestingly, radio broadcasts reached 8.2% of the participants, indicating their potential as a communication channel for breastfeeding education.

The data revealed that 83% of the adolescent mothers did not desire their pregnancies, reflecting a significant proportion of unintended pregnancies among this population. The majority of the adolescent mothers (90.2%) had only one child, while a smaller proportion (9.8%) had two children. The type of delivery experienced by the participants was another factor of interest in the study. It was observed that 90.7% of the adolescent mothers had a normal delivery, while 9.3% underwent a caesarian section. The data indicated that the majority of participants had received regular ANC visits, with 18.6% having one visit, 21.6% having two visits, 30.9% having three visits, and 25.3% having four visits. A smaller proportion (3.6%) had five ANC visits.

Table 1

Demographic and maternal characteristics of adolescent mothers
Characteristics	Frequency (N)	Percent (%)
Age
15–17	60	30.9
18–19	134	69.1
Level of Education
No formal education	38	19.6
Primary education	73	37.6
Secondary education	31	16
College/University	4	2.1
TVET/VTC	48	24.7
Occupation
Farmer	32	16.5
Casual	54	27.8
Private employee	12	6.2
Self-employed	28	14.4
Student	18	9.3
Not employed	50	25.8
UBUDEHE Category
I	4	2.1
II	50	25.8
III	140	72.2
Estimated income per month
Below 50,000Frw	182	93.8
50,000Frw-100,000Frw	12	6.2
Marital status
Single	151	77.8
Married	1	0.5
Living together	42	21.6
Religion
No religion	25	12.9
Catholic	64	33
Protestant	38	19.6
Muslim	24	12.4
Other, specify	43	22.2
Region
Urban	81	41.8
Rural	113	58.2
Source of information
Radio	16	8.2
Health facility	111	57.2
Community health worker	25	12.9
Other	42	21.6
Previous pregnancy desire
Yes	33	17
No	161	83
Number of children
1	175	90.2
2	19	9.8
Delivery type
Cesarean section	18	9.3
Normal delivery	176	90.7
ANC Visits
1	36	18.6
2	42	21.6
3	60	30.9
4	49	25.3
5	7	3.6

Source: Primary data, 2023

The level of knowledge on exclusive breastfeeding among adolescent mothers in the Nyagatare district

Table 2 presents the participants' knowledge regarding exclusive breastfeeding in the Nyagatare district, along with the mean scores for each statement. The findings reveal areas where adolescent mothers may have gaps in their knowledge regarding exclusive breastfeeding.

First, a significant majority of the participants (97.4%) demonstrated a good understanding of the importance of breastfeeding, as reflected by the mean score of 1.04, which is close to the optimal score of 1. Second, 76.2% of the participants believed that bottle feeding is dangerous for the baby, resulting in a higher mean score of 2.44. Regarding knowledge of EBF, more than half of the participants (56.2%) demonstrated an understanding of what EBF entails, with a mean score of 1.53, indicating a moderate level of awareness.

The data also revealed that a substantial proportion of the participants (85.6%) had heard about EBF, as indicated by the mean score of 1.14, suggesting a good level of exposure to this specific breastfeeding practice. Additionally, only 62.9% of the participants correctly acknowledged that breast milk alone is sufficient for infants under six months of age, with a mean score of 1.7, indicating a potential area for improvement in understanding the recommended breastfeeding duration. Furthermore, 55.2% of the participants were aware that breast milk alone can sustain a baby's nutritional needs for the first six months of life, as reflected by the mean score of 1.81, which is close to the optimal score of 1.

On the topic of EBF's preventive effects, a minority (30.9%) recognized that exclusive breastfeeding can prevent diarrheal and respiratory illnesses, with a mean score of 2.26, suggesting a considerable knowledge gap in this area. Moreover, only 18.6% of the participants were aware that exclusive breastfeeding can provide some level of protection against pregnancy, as indicated by the mean score of 2.21, suggesting a need for greater awareness in this regard. In terms of feeding expressed breast milk, a moderate proportion (32.5%) correctly acknowledged that it is suitable for feeding the baby when necessary, as reflected by the mean score of 2.11.

An overwhelming majority of the participants (93.8%) demonstrated awareness that babies should be breastfed on demand, with a mean score of 1.09, indicating a good understanding of the recommended breastfeeding practice. Regarding the comparison between EBF and formula feeding, approximately half of the participants (49.5%) recognized that exclusive breastfeeding was superior to formula feeding, with a mean score of 2.01, suggesting some misconceptions regarding this comparison. Furthermore, a substantial majority of the participants (59.8%) correctly acknowledged the nutritional benefits of colostrum for the child, as indicated by the mean score of 1.8, suggesting a general understanding of its importance.

Similarly, more than half of the participants (63.9%) were aware that breastfeeding without adding anything else is sufficient to provide the necessary nutrients for the baby, with a mean score of 1.71, suggesting a moderate level of knowledge in this aspect. Finally, a notable proportion of the participants (60.3%) recognized that exclusive breastfeeding can enhance the baby's immune system, with a mean score of 1.78, indicating a moderate level of awareness of its immunological benefits.

Table 2

The level of knowledge on exclusive breastfeeding among study respondents in the Nyagatare district
Statement about knowledge regarding exclusive breastfeeding	Yes		No		Mean	SD
Statement about knowledge regarding exclusive breastfeeding	Frequency (N)	Percent (%)	Frequency (N)	Percent (%)	Mean	SD
Know the importance of breastfeeding	189	97.4	5	2.5	1.04	0.266
Think bottle feeding dangerous for the baby	148	23.7	16	76.2	2.44	0.851
Ever heard about EBF	166	85.6	28	14.4	1.14	0.352
Know that Breast milk alone is enough for infants < 6months of life	122	62.9	72	37.1	1.7	0.93
Know breast milk alone can sustain baby for 6 months	107	55.2	87	44.8	1.81	0.938
Know EBF prevents diarrheal, respiratory (EBF protects baby from illness)	60	30.9	134	69.1	2.26	0.904
Know EBF protects the mother from pregnancy	36	18.6	158	81.4	2.21	0.733
Know expressed breast milk should be fed to the baby	63	32.5	131	67.5	2.11	0.866
Know a baby should be breastfed on demand	182	93.8	12	6.2	1.09	0.364
EBF is better than formulae feeding	96	49.5	98	50.5	2.01	1
Colostrum is nutritionally beneficial to child.	116	59.793814	78	40.20619	1.8	0.983
Breastfeeding your baby without adding anything will provide the nutrients your baby needs	124	63.9	70	36.1	1.71	0.95
Exclusive breastfeeding improves/boosts the baby's immunity.	117	60.3	77	39.7	1.78	0.97

Source: Primary data, 2023

Overall knowledge level

To calculate the knowledge level, the proportion of participants with good knowledge and poor knowledge based on their responses in the table was determined. Since "Yes" was coded as 1 (indicating good knowledge) and "No" was coded as 2 (indicating poor knowledge), the mean scores were used to categorize the participants' knowledge. The cutoff was 1.5, and all respondents with less than that cutoff were categorized as having good knowledge.

According to the data, 85.6% of the participants demonstrated good knowledge regarding exclusive breastfeeding. This indicates that a significant majority of the adolescent mothers in the Nyagatare district had a good understanding of various aspects related to exclusive breastfeeding. On the other hand, 14.4% of the participants exhibited poor knowledge about exclusive breastfeeding.

The attitudes of adolescent mothers toward exclusive breast-feeding in the Nyagatare district

Table 3 shows that a majority (56.7%) strongly agreed, and an additional 27.3% agreed that providing breast milk to a newborn within the first hour after birth is crucial. responses were predominantly in disagreement (34.5%) or strong disagreement (17.5%) with discarding the first milk. Some participants (39.7%) strongly agreed or agreed that hygiene is important, while others (41.7%) held a neutral or disagreed stance. An overwhelmingly positive attitude emerged regarding the impact of breastfeeding on mother–child bonding. Nearly all participants (97.9%) strongly agreed that breastfeeding enhances this bond.

Table 3

The attitudes of adolescent mothers toward exclusive breast-feeding in the Nyagatare district
Statement about attitudes toward contraceptive methods	Strongly agree N(%)	Agree N(%)	Neutral N(%)	Disagree N(%)	Strongly disagree N(%)	Mean	SD
Giving breast milk for a newborn immediately within one hour (early initiation) is important.	110 (56.7)	53 (27.3)	31 (16.0)	0 (0.0)	0 (0.0)	1.59	0.751
Discarding the first milk or colostrum is important.	0 (0.0)	0 (0.0)	93 (47.9)	67 (34.5)	34 (17.5)	3.7	0.752
Maintaining hygiene is more important for breastfeeding.	21 (10.8)	56 (28.9)	36 (18.6)	59 (30.4)	22 (11.3)	3.03	1.219
The breastfeeding increases mother child bonding.	190 (97.9)	4 (2.1)	0 (0.0)	0 (0.0)	0 (0.0)	1.02	0.142

Source: Primary data, 2023

Overall attitude level

The analysis of the overall attitude level illuminated the prevailing sentiments of adolescent mothers regarding various facets of breastfeeding. A Likert scale was adopted, where participants rated their agreement with statements on a scale ranging from 1 (indicating "strongly agree") to 5 (indicating "strongly disagree"). By examining mean scores and their implications, a comprehensive portrait of attitudes emerged. A threshold of 2.5 was used as a demarcation between good and negative attitudes, where scores below this threshold signify positive attitudes.

The study revealed that a substantial proportion (78.9%) of adolescent mothers in the Nyagatare district exhibited positive attitudes toward exclusive breastfeeding practices. This majority demonstrated agreement or strong agreement with statements, indicating a commendable understanding of its significance. A smaller percentage (21.1%) exhibited negative attitudes, suggesting areas for targeted interventions.

The practice of exclusive breastfeeding among adolescent mothers in the Nyagatare district

The practices toward exclusive breastfeeding among adolescent mothers were assessed, and the findings are presented in the following table. The findings, as indicated in Table 4, reveal that a substantial percentage of adolescent mothers (27.3%) practice exclusive breastfeeding. Breastfeeding frequency varied, with a majority adopting a random approach (54.6%), while some breastfed on demand (24.7%) or at constant intervals (20.6%). Occupation appeared to impact exclusive breastfeeding for a notable portion (37.6%). While approximately 26.8% adhered to the recommended six-month duration of exclusive breastfeeding, diverse practices were observed.

Table 4

The practice of exclusive breastfeeding among respondents
Variables	Frequency	Percentage
Practice exclusive breastfeeding
Yes	53	27.3
No	141	72.7
Breastfeeding frequency
On demand	48	24.7
At constant intervals	40	20.6
Randomly	106	54.6
Occupation ever stopped exclusive breastfeeding
Yes	73	37.6
No	121	62.4
Duration of breastfeed infant for the first 6 months without giving a baby any other food or drink, not even water
1	35	18
2	30	15.5
3	44	22.7
4	26	13.4
5	3	1.5
6	52	26.8
7	4	2.1

Source: Primary data, 2023

Overall practice level

The overall practice level toward breastfeeding was determined by the proportion of adolescent mothers who agreed to exclusively breastfeed their recent child. The findings shown in the graph indicate that a notable proportion (27%) of adolescent mothers reported exclusively breastfeeding their infants.

Factors associated with the practice of exclusive breastfeeding among adolescent mothers in the Nyagatare district

As indicated in Table 4.6, regarding education, adolescent mothers with primary education (AOR = 1.161, 95% CI = 1.721–2.319, p = 0.009) and mothers with secondary education (AOR = 3.056, 95% CI = 2.006–5.542, p = 0.013) demonstrated greater odds of practising exclusive breastfeeding than did those with no formal education. Occupation also exhibited notable associations. Adolescent mothers categorized as casual workers (AOR = 2.041, 95% CI = 0.556–7.497, p = 0.282) displayed greater odds of practising exclusive breastfeeding, while those with self-employed occupations (AOR = 0.818, 95% CI = 0.152–4.411, p = 0.815) showed decreased odds.

Urban residence was significantly associated with increased odds of practicing exclusive breastfeeding (AOR = 1.622, 95% CI = 1.038–3.089, p = 0.007) compared to rural residence, and previous pregnancy desire was associated with significantly decreased odds of exclusive breastfeeding (AOR = 0.204, 95% CI = 0.051–0.817, p = 0.025).

The number of children also played a role, where having one child was associated with decreased odds of exclusive breastfeeding (AOR = 0.418, 95% CI = 0.037–0.792, p = 0.043) compared to having two children. Attitude and knowledge levels were significant predictors. A positive attitude was strongly associated with increased odds of practicing exclusive breastfeeding (AOR = 5.702, 95% CI = 1.633–19.91, p = 0.006), as was having good knowledge (AOR = 2.403, 95% CI = 1.032–4.926, p = 0.002).

Table 6

Multivariable analysis - Factors associated with practices related to exclusive breastfeeding.
Variables	AOR	95% CI (AOR)		P Value
Variables	AOR	Lower	Upper
Level of Education
No formal education	1*
Primary education	1.161	1.721	2.319	0.009
Secondary education	3.056	2.006	5.542	0.013
College/University	1.066	0.001	2.912	0.159
TVET/VTC	0.033	0.003	0.354	0.305
Occupation
Farmer	1.202	0.236	6.124	0.825
Casual	2.041	0.556	7.497	0.282
Private employee	1.07	0.092	12.488	0.957
Self-employed	0.818	0.152	4.411	0.815
Student	1.962	0.144	26.828	0.613
Not employed	1*
Region
Urban	1.622	1.038	3.089	0.007
Rural	1*
Previous pregnancy desire
Yes	1*
No	0.204	0.051	0.817	0.025
Number of children
1	0.418	0.037	0.792	0.043
2	1*
Knowledge level
Good knowledge	2.403	1.032	4.926	0.002
Poor knowledge	1*
Attitude level
Positive attitude	5.702	1.633	19.91	0.006
Negative attitude
Reference	1*

According to the findings of our study, a notable proportion of adolescent mothers in the Nyagatare district demonstrated a commendable level of knowledge regarding exclusive breastfeeding. Specifically, 85.6% of the participants exhibited good knowledge of various aspects related to exclusive breastfeeding, reflecting a substantial understanding of the recommended infant feeding practices. Our finding is positioned slightly above the knowledge level reported in the systematic review conducted in East Africa [16]. While our study focused specifically on adolescent mothers in the Nyagatare district, the systematic review encompassed a broader scope of mothers in East Africa and reported that 59.3% did not know the benefits of exclusive breastfeeding for babies and mothers. agai, this finding is far greater than that obtained from a study conducted in Ethiopia [17], which revealed that only 34.7% of adolescent mothers had good knowledge of EBF.

The study revealed that 3 in 4 (78.9%) adolescent mothers had positive attitudes toward exclusive breastfeeding. This attitude level is below that obtained from a study conducted by [17] in Ethiopia. Comparing these findings suggests potential variations in attitude levels between different populations and geographical locations. While our study focused on adolescent mothers in the Nyagatare district, the Ethiopian study included a broader range of mothers. This difference in participant characteristics and cultural contexts could contribute to the observed variation in attitude levels.

Our findings indicate that while a majority of adolescent mothers in Nyagatare still demonstrated positive attitudes toward exclusive breastfeeding (78.9%), the proportion is lower than that reported in the Mpigi study (95%) [18]. This disparity is attributed to differences in the research setting. The Mpigi study included a broader range of mothers attending health clinics; therefore, the variation in participant characteristics and healthcare settings could have contributed to the observed differences in attitudes [18].

This study's practice level of exclusive breastfeeding among adolescent mothers (27.3%) is notably lower than that reported in the study conducted by [18], where the majority of mothers (62.5%) initiated breastfeeding within the first hour of birth and a significant proportion (85%) introduced complementary feeds to their babies between 4–5 months. The differences in practice levels could stem from various factors, such as socioeconomic disparities, cultural norms, access to healthcare services, and educational interventions. The unique challenges faced by adolescent mothers, including lack of proper guidance and support, could contribute to the observed lower practice level.

The obtained practice level appears to be slightly lower than that reported in a comparative study conducted in Lagos, Nigeria, where 79.8% of rural mothers practiced or were currently practicing EBF, and 29.0% of urban mothers engaged in EBF. Factors contributing to this difference could involve variations in cultural practices, support systems, and access to healthcare services between the study locations [19].

This study revealed that adolescent mothers with primary education (AOR = 1.161, 95% CI = 1.721–2.319, p = 0.009) and secondary education (AOR = 3.056, 95% CI = 2.006–5.542, p = 0.013) exhibited greater odds of practising exclusive breastfeeding than did those with no formal education. Similarly, a study by [19] revealed that maternal employment (AOR = 0.62, 95% CI: 0.44–0.87) and being head of a household (AOR = 0.52, 95% CI: 0.32–0.83) were significantly associated with exclusive breastfeeding. These shared findings suggest that education and socioeconomic factors play pivotal roles in influencing exclusive breastfeeding practices across different settings.

This study revealed that urban residence was associated with increased odds of practising exclusive breastfeeding (AOR = 1.622, p = 0.007), while a study conducted by [20] in Ethiopia indicated that urban women had a lower rate of exclusive breastfeeding (29.0%) than did their rural counterparts (79.8%). These contrasting findings suggest a complex interplay of urbanization, work resumption, and other contextual factors influencing exclusive breastfeeding practices in different regions.

In our study, adolescent mothers with good knowledge (AOR = 2.403, p = 0.002) and positive attitudes (AOR = 5.702, p = 0.006) were more likely to practice exclusive breastfeeding. Similarly, a study conducted in Southwest Korea indicated that mothers who received breastfeeding information were significantly more likely to exclusively breastfeed (AOR = 2.46, p = 0.0009) [21]. These findings emphasize the crucial role of education and information dissemination in promoting exclusive breastfeeding behaviors. Both studies underscore the significance of socioeconomic factors in influencing exclusive breastfeeding practices.

The study revealed that positive attitudes (AOR = 5.702, p = 0.006) and good knowledge (AOR = 2.403, p = 0.002) were associated with greater odds of exclusive breastfeeding. This finding aligns with findings from a study conducted in Ethiopia indicating that colostrum feeding was associated with increased odds of exclusive breastfeeding (AOR = 2.3; 95% CI 1.3, 3.9). Both studies emphasize the importance of antenatal care. In our study, antenatal care was associated with exclusive breastfeeding (AOR = 2.1; 95% CI 1.1, 4.3), while another study also revealed a positive association between antenatal care and exclusive breastfeeding (AOR = 2.1; 95% CI 1.2, 3.3). This suggests that receiving proper care and information during pregnancy can positively influence breastfeeding practices [22].

Overall, our study underscores adolescent mothers' commendable knowledge and positive attitudes toward exclusive breastfeeding in the Nyagatare district. Strategies should focus on reinforcing these strengths to enhance exclusive breastfeeding practices.

Conflict of interest declaration

The authors affirm that the study was conducted without any conflicts of interest. Each author consented to submit the manuscript to the present journal, taking full responsibility for all aspects of the research and approving the final version for publication.

Author contributions

Mugabo. J devised and executed the study, with oversight from C. Nishimwe and O. Marette, who provided supervision and feedback and contributed to the study protocol.

Consent for publication:

I, Jackson Mugabo, hereby grant permission to the International Breastfeeding Journal to publish the following manuscript titled:

“Knowledge, attitude and practices towards exclusive breastfeeding and associated factors among adolescent mothers in Nyagatare district, Rwanda”

This consent covers the publication of the aforementioned manuscript in the International Breastfeeding Journal.

I understand that this consent allows the International Breastfeeding Journal to publish the manuscript as described above, and I retain the right to be identified as an author of the manuscript.

JACKSON MUGABO

Mount Kenya University

Availability of data and materials

All data are available in this manuscript, but they can be shared upon request from the primary author

Competing interests

The authors declare that they have no competing interests

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Authors’ contribution

Dr. Clemence Nishimwe, PhD: Provided substantial guidance and supervision throughout the research process, ensuring the integrity and quality of the study.

Mr. Onesmus Marete: Contributed to the overall direction and supervision of the research, ensuring methodological rigor and academic integrity.

Acknowledgements

The authors gratefully acknowledge Springer Nature for their role in publishing this work. We appreciate their editorial support and commitment to advancing scientific knowledge through rigorous peer review and publication. Special thanks are also due to Dr. Clemence Nishimwe PhD, and Onesmus Marete for their valuable guidance and assistance throughout the study. The authors also acknowledge the participants who generously gave their time and shared their experiences. Their contributions were indispensable to the successful completion of this research

Authors' information

Author 1: Jackson Mugabo
Mount Kenya University Rwanda
Public Health Department
Kigali City, Rwanda
[email protected]

Author 2 : Dr. Clemence Nishimwe PhD
Mount Kenya University Rwanda
Department of Nursing
Kigali City, Rwanda
[email protected]

[Author 3: Mr Onesmus Marete
Mount Kenya University Kenya
Public health departiment
Nairobi City, Kenya
[email protected]

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No competing interests reported.

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Knowledge, Attitude, and Practice Towards Exclusive Breastfeeding and Associated Factors Among Adolescent Mothers in Nyagatare District, Rwanda

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Abstract

Figures

INTRODUCTION

MATERIALS AND METHODS

Data collection instrument and procedures

Data Analysis

Ethical consideration

RESULTS

Demographic characteristics of the respondents

Source: Primary data, 2023

The level of knowledge on exclusive breastfeeding among adolescent mothers in the Nyagatare district

Source: Primary data, 2023

Overall knowledge level

The attitudes of adolescent mothers toward exclusive breast-feeding in the Nyagatare district

Source: Primary data, 2023

Overall attitude level

The practice of exclusive breastfeeding among adolescent mothers in the Nyagatare district

Source: Primary data, 2023

Overall practice level

Factors associated with the practice of exclusive breastfeeding among adolescent mothers in the Nyagatare district

DISCUSSION

CONCLUSION

Declarations

References

Additional Declarations

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