Barrier and Motivation to Exclusive Breast Feeding Amongst Mothers Accessing Care at the University of Abuja Teaching Hospital

This study was carried out to identify barriers and motivation for exclusive breastfeeding practice amongst mothers accessing care at the University of Abuja Teaching Hospital, ( UATH) — Abuja — Nigeria. The study was a crosssectional survey that utilized a structured questionnaire in the collation of quantitative data from 288 participants. The data and result showed that approximately 53.5% of the respondents reportedly do not have enough breast milk, 13.9% think that the breast milk will not be enough for their babies because of the size of their breast, 0.69% were the students with attendant challenges, 1.4% were career women, 1.7% said their difficulty was painful nipples, one person was afraid that the baby may refuse other feeds at a later age while one respondent said it was time-consuming. It is captivating to know that, the respondents’ motivation based on whether exclusive breastfeeding is beneficial to baby and mother shows that 99.6% claimed that exclusive breastfeeding is beneficial, and contribute to the good well-being of the baby, while 98.2% declared that exclusive breastfeeding is beneficial to the nursing mother as well. The study evaluated the barriers, and motivations of the mother to tell the benefits of breast milk are natural and renewable food. Therefore, ensuring active support through an efficient health education/promotion as primary prevention in public health/clinical practice and establishing/sustaining the practices that are appropriate among mothers. Generally, the study showed some barriers to exclusive breastfeeding and their associated motivations among mothers.


Introduction
An extensive body of research has confirmed that mothers and other caregivers require active support for establishing and sustaining appropriate breastfeeding practices. World Health Organization (WHO) and United Nations Children's Fund (UNICEF) launched the Baby-friendly Hospital Initiative in 1992, to strengthen maternity practices in supporting breastfeeding [1]. The findings suggest that early initiation of breastfeeding reduces neonatal, and early infant mortality both through increasing rates of exclusive breastfeeding and by additional mechanisms [2]. Recommendation that, both practices should be promoted by public health program and be used in models to estimate saving lives. According to WHO, "Exclusive breastfeeding " is defined as no other food or drink, not even water, except for breast milk (including milk expressed or from a wet nurse) for 6 months of life, but allows the infant to receive ORS, drops, and syrups (vitamins, minerals, and medicines) [33]. Interestingly, most children progressively gain weight and grow quickly within the first few years of life. Though, in some cases, some children may not meet these expected standards of growth. And when this happens, it can be said that there are infants' malnutrition, growth retardation, and eventually failure to thrive. Many things can cause malnutrition, growth retardation, or failure to thrive and these include illnesses and eating problems. When the cause of the problem is identified, then the families especially the mother will need to be motivated in correcting malnutrition [28]. Usually, after birth, a child's brain grows as much in the first year as it will grow for the rest of a child's life. Hence, poor nutrition during this period may have lasting harmful effects on brain development. Children who fail to thrive due to retard growth usually don't meet the commensurate milestones as expected. There is a need to achieve the health-related Sustainable Development Goal (SDG) 3 by ensuring that this global goal is met, starting from the grass root [21]. Also, there is so much evidence confirming that breastfeeding presents short and long-term advantages for infants, mothers, and the global community. Breast milk contains all the essential nutrients which stimulate optimal physiological and psychological growth and development [3][4][5][6]. In the short term, the incidence of childhood infections among breastfed children, such as diarrhea, respiratory infection, and other common childhood illnesses, tends to be lower due to the immunoglobulins present in breast milk [5]. The incidence of childhood and the risk of leukemia, the risk of being overweight or obese are also reduced [4,6]. Breastfeeding has also been found to reduce health outcomes like malocclusion [7,11]. For long-term benefits, otitis media in children up to the age of 2 years can be prevented by breastfeeding and in all breastfeeding is estimated to have saved the lives of more than 820,000 children under the age of 5 [4,8]. There is evidence that the bonding between infants and mothers could be increased by breastfeeding [8]. Benefits to the mothers arise as a result of oxytocin and prolactin release, reducing the risk of postpartum hemorrhage, in addition to promoting uterine involution [9,10]. It has also been substantiated that, breastfeeding reduces the mother's risk of certain illnesses, including ovarian cancer, type 2 diabetes, obesity, hypertension, heart disease, maternal depression, and mortality rate from breast cancer [1, 4,9,[13][14][15]. Longer periods of amenorrhea, which can lead to birth spacing, are associated with breastfeeding [12,16]. Breastfeeding has also been found to help women restore their body shape after delivery [4]. Not only health outcomes, but improvements in gender equality (in the workplace), money-saving, and fulfilling the mother's potential are other obvious benefits [17,18]. For worldwide benefits, breast milk is recognized as a natural and renewable food; and the ecological footprint of feeding infants is minimized [19]. Regarding global spending, breastfeeding can save US$ 302 billion annually [19,23]. Developmental delay results in loss of interest in their surroundings, avoid eye contact, and may not reach developmental milestones like sitting up, walking, and talking at the usual age. According to the United Nations sustainable development goal 3 (Good health and wellbeing) "We have made great progress against several leading causes of death and disease. Life expectancy has increased dramatically; infant and maternal mortality rates have declined. Good health is essential to sustainable development and the 2030 Agenda reflects the complexity and interconnectedness of the two [21]. It takes into account widening economic and social inequalities, rapid urbanization, threats to the climate and the environment, the continuing burden of HIV and other infectious diseases, and emerging challenges such as non-communicable diseases" [19,22]. The purpose of this research will cut across identifying various barriers, and the motivation that is associated with exclusive breastfeeding practice from mothers, ensuring active support by establishing and sustaining the practices that are appropriate among mothers who access care at the University of Abuja Teaching Hospital -FCT -Abuja. Also, the findings from this research will help in promoting WHO and UNICEF programs domesticate the programs and to ensure the goal of SDG 3 through efficient health education, and promotion as primary prevention in public health and clinical practice.

Study Setting
The study was undertaken in two Departments of the University of Abuja Teaching Hospital, Gwagwalada, Abuja, North Central Nigeria, namely the Post Natal Outpatient Unit (Department of Obstetrics and Gynecology) and National Program on Immunization (NPI) Unit (Department of Community Health Medicine)

Data Collection Methods
This is a descriptive cross-sectional study and clients were selected by a systematic random sampling method. The data collection tool was an open-ended quantitative questionnaire with two domains that speak to barriers and motivations of mothers as they visit the clinics during puerperium. The interviews were carried out by one trained data collector. And data collection took place from February 2020 -August 2020. Inclusion criteria were mothers aged 20 to 40 years, who had children aged between 0 -6 months, and mothers who are currently breastfeeding. While the exclusion criteria were mothers who were very ill e.g. eclampsia, mental health derangement, mothers who were unconscious, and children who were also very ill.

Study Participants
Study participants were recruited from a high patient load unit. The minimum sample size for the number of patients who were interviewed was calculated using the Leslie and Kish formula for descriptive studies (Z2pq/d2 where z = 1.96) [23]. There were 288 mothers in all.

Ethical Considerations
Ethical approval for the study was obtained from the Research Ethical Committee of the University of Abuja Teaching Hospital, Gwagwalada -Abuja.
Each participant gave their informed consent before participating in the study, and their anonymity, privacy, and confidentiality was respected. Consent was signed and obtained after reading and understanding the content of the consent form.

Data Management and Analysis
This deals mainly with the presentation and analysis of data collected from the respondents. The main purpose of this study was to investigate the barrier and motivation to Exclusive Breast Feeding (EBF) amongst mothers accessing care at the University of Abuja Teaching Hospital. Descriptive data analysis was done and the information collected was statistically presented through the use of percentages and graphs. Data from the questionnaire was cleaned, coded, and fed into Statistical Package for Social Sciences (SPSS) soft-ware 21 Version, for analysis. Microsoft Excel spreadsheet was used to provide means, frequency, and drawing various charts.

Mother and Antenatal
The figure 2 shows respondents' number of Antenatal visit and Health talk topics at antenatal clinic. 2 (0.69%) of the total respondents claimed to have attended antenatal only one time, 63 (21.88%) attended 2 times, 121 (42.01%) attended 3 times, 48 (16.67%) attended antenatal 4 times, 51 (17.71%) attended 5 times and 3 (1.04%) of the respondents attended antenatal more than 5 times before delivery. Regarding, health talk topic at antenatal clinic, 97.57% of the respondents attested that nurses taught them about Exclusive Breast Feeding (EBF), 89.93% learnt about the benefit of EBF. Barrier to Exclusive Breast Feeding (BEBF) and 82.64% were taught the risk of giving water, formula or other supplements (Risk -NEBF) to babies before six months of age. Concerning mode of delivery, 228 (79.17%) of the respondents claimed that, they deliver their babies through Normal Vaginal delivery, while 60 (20.83%) delivered their babies through Caesarean Section (see figure 2).

Feeding Pattern
Apropos to respondents feeding of their baby, 83.7% of the total respondents were Breast-feeding Exclusively (EBF), 4.9% said they adopted both breastfeeding/feeding breast-milk substitutes (BOTH) method, 6.3% preferred feeding my baby breast-milk substitutes while 4.5% were not breastfeeding at all (Not at) (see figure 3).

Attitude of Mother Toward Their New-born Babies
The result of the attitude of mothers toward their new baby shows how mothers were bonded to their new-born babies. 122 (43.6%) claimed that they held their babies immediately after birth, 72 (25.7%) said within 5 minutes after birth, 55 (19.6%) within 30 minutes, 9 (3.2%) within 1 hour, 19 (6.8%) admitted that as soon as they were able to respond after surgery for those who delivered through cesarean section, only 1% of the respondent can't remember when they first held their babies after delivery. The result also indicates, "how soon mothers initiate breastfeeding after birth," 98 (36.43%) started immediately, 49 (18.22%) initiated breastfeeding between 10 to 20 minutes, 22 (8.2%) initiated it after 30 minutes, 4 (1.5%) after 40 minutes, 5 (1.9%) after 50 minutes, 16 (5.5%) claimed to initiate breastfeeding after 1 hour of delivery while 9.7% of the respondent can't even remember when they did. Concerning how often respondents feed their babies, 10 (3.5%) feed their babies every 10 minutes, 4 (1.4%) feed every 20 minutes, 9 (3.2%), feed every 30 minutes, 19 (6.7%) feed every 1 hour, 232 (82%) claimed to feed their babies on demand, 1 (0.4%) feed anytime they have a chance while 8 (2.8%) can't remember how often they feed their babies. Based on how long 17

Barriers Experiencing as It Regards Exclusive Breast Feeding
The results of barriers experiencing by mother regarding Exclusive breastfeeding depicts that, 53.5% of the respondents contend with the challenge of not having enough breast milk, 13.9% think that the breast milk will not be enough for their babies because of the size of their breast, 0.69% have the challenge of being a student, the limitation of 1.4% of the respondent is being a career woman, 1.7% difficulty is painful nipples, only one person was afraid that the baby may refuse other food at a later age also, one respondent said it's time-consuming.

Motivation
Respondents' motivation based on whether, exclusive breastfeeding is beneficial to baby and mother shows that 99.6% of the respondent claimed that exclusive breastfeeding is beneficial, and contribute to good well-being of the baby, also 98.2% of respondents submitted that exclusive breastfeeding is beneficial to the nursing mother as well.

Discussions
Exclusive breastfeeding (EBF) is widely known to improve children's health, but poor breastfeeding rates are still reported in many developing countries, including Nigeria. This study shows that 53.5% of the respondents reportedly did not have enough breast milk, 13.9% think that the breast milk will not be enough for their babies because of the size of their breast, 0.69% have the challenge of being students whiles the limitation of 1.4% of the respondent is that they are career women. Only 1.7% complained of painful nipples; one person was afraid that the baby may refuse other food at a later age and one respondent said it's time-consuming.
The above maternal-baby factors such as the perceived insufficiency of milk have been reported previously as a key factor leading to early breastfeeding cessation  [32] maintain that only about 5% of women actually have physiological insufficient milk supply but up to 50% of mothers report to health facilities about insufficient milk for their baby. The motivation for breastfeeding is an important variable which should be considered, given that motivation is the agent propeller of all action [29].
Also, Hill & Aldag explain this perception about the lack of breast milk results from doubting one's breastfeeding ability, which may lead to the perception of insufficient milk supply and adding other food, or fluids to the baby's diet [31].
Likewise, Justine A. Kavle et al. [30] agreed that poor latching and positioning perceived insufficient breast milk and breast engorgement are barriers to EBF. They also concluded from their findings that the providers often lacked the knowledge, skillset, and self-efficacy to manage EBF problems, with little counseling provided at community or facility levels. And discovered that, provision of job aid rollout, providers reported improved assessment of breastfeeding technique, and increased self-efficacy and motivation to identify and resolve EBF problems [24]. Other authors found related reasons such as EBF was very stressful (26.2%; n = 67), mother's refusal (23.5%; n = 60), EBF was not necessary (18.1%; n = 46), time constraints, 35 (13.7%) the husband's refusal accounted for 1.5% (n = 3) of the reasons for the non-practice of exclusive breastfeeding. (Ugboaja JO, Bertrand NO, Igwegbe AO, Obi-Nwosu AL).
Barriers to postnatal care and exclusive breastfeeding amongst urban women in south-eastern Nigeria. [25] Khasawneh, W. et. al found that besides multiparity, the main predictive factor for the success of EBF was the mother's own experience with EBF in her previous children. Also, Kitano N, Nomura K et. al, and Hackman N M et. al [26,27,33] further substantiates these findings which had claimed that it is not unexpected as most of the difficulties in breastfeeding are usually reported in young and nulliparous mothers, and these mothers need to be a target group with better education and support about the benefits, and techniques of breastfeeding to improve their future experiences.

Conclusion
The study has revealed some of the barriers to exclusive breastfeeding amongst mothers accessing care at the