This study was designed to assess breastfeeding knowledge, beliefs, and perceived behavior and their impact on breastfeeding intention among female tertiary students in Ekiti State, Southwest Nigeria.
The study revealed that just a little above average of the respondents (58.8%) had understanding of what exclusive breastfeeding (EBF) means, this is quite less than the 69% recorded by Shehu and Shehu in their study among clinical medical students in Jos [19].This is not unexpected as the participants in this study are not studying medical related courses as it has been documented that students in health-related majors have significantly higher levels of breastfeeding knowledge [22]. The finding may also be a true reflection of what obtains in the larger society. The study participants demonstrated poor understanding of the infant feeding practices. This is evident by the fact that only 25% of them had correct understanding of what predominant breastfeeding means, 14.6% for complementary feeding and 18.4% for prolonged breastfeeding. This result pattern shows that there is need to educate the future mothers on the different infant feeding practices and this could allow them to make a better decision later in life. As much as 34% of the respondents erroneously chose water administration in addition to breastfeeding in the first 6 months of life as exclusive breastfeeding and are likely to give their infants water prior to 6 months of life. This result shows that there is a knowledge gap regarding what exclusive breastfeeding means. Previous studies however did not evaluate these terminologies among their respondents.
The study showed that the study respondents had good understanding that breastmilk is important for brain development as that was the only response with consensus index above 80 which was considered an indication of good knowledge of the benefits of breastfeeding. Even though, the consensus index for other indices of the knowledge of the benefits of breastfeeding were higher than 50, almost all the indices were below the score of 80 and this shows that gaps exist in their knowledge of breastfeeding and its benefits for both the child and mother and this may have effect on their perception of breastfeeding. This is not surprising as breastfeeding is not taught in elementary or secondary schools in Nigeria thus leaving these future mothers to acquire knowledge about breastfeeding and breast milk on their own or from unverified sources. Among the women of reproductive age groups, reliable information about breastfeeding are often times first heard during pregnancy during antenatal care provided that the lady registers for antenatal care and by which time many of them could have been wrongly informed and wrong opinions about breastfeeding already formed which might be difficult to change. The findings of this study are not different from that of Shehu and Shehu in Jos [19] among clinical medical students, Padmanabhan et al [23] among female college students in India and Anjun et al [24] among medical students in Pakistan.
Major knowledge gaps identified among these students included misconceptions that breast milk alone is inadequate for an infant in the first 6 months of life, water can be given to infants within the first 6 months of life, size of a woman’s breast determines the volume of milk produced, exclusive breastfeeding can hinder infants from taking complementary feeds and that breastfeeding makes the breast to sag amongst others. Interestingly, some of these misconceptions were also documented by previous studies; Hamade et al [25] documented similar finding among female undergraduate students in the middle East – Syria and Lebanon. Osman et al also documented similar findings among Lebanese mothers and concluded that many of these misconceptions were derived from the local culture [26]. The perception by about 50% of the study respondents that breastfeeding makes the breast to sag was also reported in the study by Nabulusi et al [27] among mothers in Lebanon; this was also reported by Hamade et al [25] in the study among female undergraduate university students in Lebanon and Syria. The major implication of this wrong perception is that these future mothers will likely discontinue breastfeeding earlier than the recommended time.
The opinion held by about 34% of the participants that breastfeeding in the public is offensive is similarly high like the findings of Hamade et al [25] in which more than 50% of their study respondents had negative behavioural perception towards breastfeeding in the public and were against breastfeeding in public places or even in the presence of neighbors or friends in the home setting. This negative attitude towards breastfeeding in the public which probably is due to societal disapproval will not encourage breastfeeding especially exclusive breastfeeding. If the infant of such a mother cries for breast milk in a place the mother considers not secluded enough, she would probably give breastmilk substitute which would not only avoid “embarrassing” exposure of her breast but may also be erroneously considered a display of “class”. These negative perceptions, coupled with the lack of public facilities to breastfeed comfortably, have ominous implications for breastfeeding and this may make it difficult to improve the exclusive breastfeeding rate in some developing countries, especially Nigeria. This concern has been raised by authors of previous studies [28, 29, 30, 31], although studies investigating this issue in Nigeria are scanty.
Another knowledge gap identified by this study is that the study participants do not know how soon after delivery a newborn baby should commence breastfeeding. Only 4% of the respondents knew that newborn babies should be breastfed within one hour of delivery. This major knowledge gap puts the newborn at risk of hypoglycaemia and being offered pre-lacteal feeds, which increases the risk of sepsis, hence morbidity and mortality in such babies. This probably may be due to poor nutrition education among Nigerian students. There is need to integrate breastfeeding education into the nutrition curriculum right from the elementary school level to deepen the knowledge of the future parents on breastfeeding and associated benefits.
The source of information for most of the participants who responded to this question was mainly sayings of old women who are likely to be relatives such as mothers and grandmothers. Only 4.4% of the respondents got their information from the hospital or clinic, however 59% of the study participants did not respond to this question.
Most of the respondents showed good understanding of only exclusive breastfeeding irrespective of their source of information but majority have poor understanding of predominant breastfeeding, complementary feeding, and prolonged breastfeeding. Their knowledge of infant feeding practices was also not influenced by the faculty of study. These observations show that information has a role to play with understanding, hence the need to ensure that correct information about breastfeeding is passed across to the future mothers. The Faculty of study did not have effect on the participants knowledge of infant feeding practices, this might reflect the defect in the education system and the basic knowledge acquired by the participants during their elementary school days.
Intention is an important antecedent of behavior [25], and surprisingly, the intention to breastfeed by participants in this study is abysmally poor at 34% when compared with reports from the study by Shehu and Shehu in Jos [19] who reported intention to breastfeed of about 66% among clinical medical students. The study by Padmanabhan et al [23] in India showed as high 98.4% of the participants responding affirmatively, the study by Hamade et al [25] among Syrian and Lebanese female undergraduate university students reported 76.4% and 88.9% respondents respectively confirming their intention to breastfeed their babies. A major concern is the fact that 58.8% of our study participants did not respond to this simple question suggesting that they could be swayed in any direction depending on who counsels them. This study also showed that a higher percentage of the respondents aged 15 to 19 years do not intend to breastfeed their babies. This attitude is probably pointing to the fact that the culture of breastfeeding babies may be declining faster than expected and this portends a major problem for the future generation. This calls for urgent action to increase awareness about the breastfeeding and its benefits among the future mothers. Hamade et al [32] have previously documented that intention to breastfeed is one of the significant predictors of exclusive breastfeeding among Lebanese mothers. However, intention appears to be modulated by several other factors, including knowledge, attitude, and behavioral perceptions [16, 33, 34].Less than 50% of the respondents believe in exclusive breastfeeding and only 44% signified their intention to practice exclusive breastfeeding. This finding also portends grave danger to the practice of exclusive breastfeeding in the nearest future except urgent measure are taken to correct these negative attitudes. It has been shown further that improving parental knowledge, attitude, and behavioral perceptions toward breastfeeding can significantly improve not only the intention to breastfeed but also the initiation and duration of breastfeeding [7, 37, 36, 37].
This study probably highlights some of the reasons why it has been difficult for Nigeria to increase her exclusive breastfeeding rate and may depict what the future holds for breastfeeding in Nigeria. This study shows that the knowledge of most of these future mothers about breastfeeding and its benefits are not good enough and this may make it difficult for some of them to make the right/ best choice when the time comes for them to breastfeed their children. Since it has been shown that mothers with good knowledge about breastfeeding will likely have positive attitude towards breastfeeding and are also likely to be prepared to breastfeed their future children [22, 38], hence there is need to improve the knowledge of these future mothers.
There are country-specific differences in the predictors of breastfeeding intention, this highlights the need to tailor breastfeeding intervention strategies to the local context and emphasizes the need for country-specific promotional tools to be used by breastfeeding advocates [25]. Even though culture specific interventions focusing on increasing knowledge and the promotion of the benefits of breastfeeding are needed to demystify some of the identified misconceptions about breastfeeding, there is also a need for implement and improve on the existing breastfeeding-friendly policies and legislation to encourage and support breastfeeding [25].
Also, the idea of waiting till antenatal period to educate would-be mothers about breastfeeding and its benefits is obviously not the best option, because some women do not attend antenatal care clinics at the appropriate health facilities as most of them prefer spiritual homes, traditional birth attendants (TBAs) and some women do not even attend antenatal care clinics which may render the current practice ineffective. Thus, there is a need for paradigm shift by starting the education of the future mothers about breastfeeding and its associated benefits early in life. Measures targeted at young women during the early school years to increase awareness not only of the benefits of breastfeeding but also of the challenges encountered by breastfeeding women can be adopted [25]. Interventions may also include school curricula revision to ensure that breastfeeding is presented as the norm in texts, other resources, and during classroom discussions in elementary and secondary schools, in addition to encouraging universities to review and update their undergraduate and postgraduate training programs to reflect this [39]. School has been classified as the most important source of information by some authors and they have also been campaigning for the implementation of breastfeeding education in the school curriculum [40]. It has been shown that providing children with appropriate information on breastfeeding at school will probably make them better adults with greater capacity to choose the best nourishment for their children [41]. This may be one of the approaches that our nation has to take since this study has shown a fair knowledge and the perception of breastfeeding among female tertiary students and a below average intention to breastfeed and exclusively breastfeed their babies. Also, a reasonably high proportion of them were undecided whether to breastfeed their babies, these ones can be convinced to breastfeed their babies if given the right counsel.
Other intervention strategies may include the use of the media as a breastfeeding awareness vehicle, as it has been shown that attitudes, social norms, and cultural opinions about infant-feeding are partially shaped by the media including books, magazines, television, videos, and the internet [42]. By mitigating the societal taboos and promoting breastfeeding as a societal norm, the media may play an important role in addressing the issue of breastfeeding in public. More so, the media was the second highest source of information among participants in this study.
Nevertheless, the study was a cross sectional design study and this may affect its ability to predict the actual behaviour of the respondents, besides, being a self-administered questionnaire study, some questions were unanswered however this is not significant enough to invalidate the findings of the study. Also, the participants of the study are students of tertiary institutions who are believed to be educated and from urban areas, hence the findings may not be directly generalizable to all population groups.
The study focused on the female gender, however, it has been previously shown that male partners may exert an influence on infant-feeding decisions [43], hence it may be worth exploring the knowledge, beliefs and perception of young men about breastfeeding as well.