Abstract

The low rate of exclusive breastfeeding (EBF) is a significant contributor to the high mortality and morbidity rates among under-five children in Nigeria. Increased female participation in the labour sector has been linked to the reduced practice of EBF. Understanding the knowledge and intention to practice EBF is crucial for designing policies aimed at achieving targets associated with Sustainable Development Goals 2 and 3. Thus, this study assessed the knowledge, intention, and practice of EBF among privately employed nursing mothers in southwestern Nigeria. A cross-sectional study was conducted among 250 working nursing mothers from the private sector in Ibadan, West Africa’s largest metropolis. Data were collected using an adapted self-administered questionnaire and analyzed using frequency, proportion, chi-square, and logistic regression. The majority (42.8%) of respondents were aged 30-34 years, while 26.4% were older than 34 years. Most respondents (74.5%) demonstrated good knowledge of EBF. Nearly 79% expressed the intention to practice EBF, yet only 51.2% adhered to exclusive breastfeeding for the recommended six months. Women under 30 years were 39% less likely to practice EBF compared to those over 34 years (AOR = 0.61, 95% CI 0.26 - 1.41). Factors such as short maternity leave, an unfriendly work environment, lack of social support, and inadequate lactation facilities were associated with the actual practice of EBF. A gap exists between the intention to practice EBF and its actual practice, primarily due to insufficient maternity leave, workplace challenges, and lack of partner support. Urgent strategies are needed to bridge this gap and promote the health and well-being of both mothers and children.

Keywords

Infant Nutrition, Maternal Employment, Workplace Support, Working Mothers, Lactation Support, Breastfeeding Barriers, Maternity Leave

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1. Background

The World Health Organization (WHO) and the United Nations International Children’s Emergency Fund (UNICEF) advocate for exclusive breastfeeding (EBF) during the first six months of an infant’s life [1]. Extensive research has demonstrated that EBF provides substantial short- and long-term health benefits for both the infant and the mother [2]. For infants, EBF significantly reduces susceptibility to infectious diseases and decreases the incidence of conditions such as diarrhoea, otitis media, bladder infections, allergic disorders, lower respiratory tract infections, and nutritional deficiency. It also promotes steady growth and cognitive development and lowers the risk of childhood hypertension, obesity, and diabetes mellitus [2] [3]. Mothers who practice EBF benefit from enhanced mother-child bonding, reduced postpartum haemorrhage, and a decreased risk of postpartum depression, type 2 diabetes, and cancers of the breast, thyroid, and ovary [4] [5].

Sub-optimal breastfeeding practices, particularly the lack of exclusive breastfeeding during the first six months, are estimated to contribute to 1.4 million deaths and account for 10% of diseases among children under five globally . The long-term consequences of inadequate breastfeeding include poor academic performance, decreased productivity, and hindered intellectual and social development. A meta-analysis study highlighted that the risk of infection-related mortality among infants under six months is highest for those who are not breastfed at all (Relative Risk “RR” of 9), followed by partially breastfed (RR of 5) and predominantly breastfed infants (RR of 2), compared to those who are exclusively breastfed [7]. It is estimated that optimal breastfeeding could prevent over 820,000 deaths annually among children under five worldwide . However, the reality falls short, with only about 44% of infants from birth to six months being exclusively breastfed [8]. The low practice of EBF continues to be a major factor contributing to the high mortality and morbidity rates among children under five in Nigeria [9]. Despite increased awareness of the benefits of breast milk, the Nigeria Demographic and Health Survey (NDHS) of 2018 reported that less than one-third (29%) of Nigerian mothers practice EBF [10]. This figure falls significantly below the WHO target of achieving at least 50% exclusive breastfeeding among infants up to six months by the year 2025 [11]. The increased participation of women in the labour sector has been linked to the sub-optimal rates of EBF [12]. Studies have shown that returning to work is the most common reason for not adhering to EBF [12] [13]. This issue is particularly acute in low- and lower-middle-income countries, where women often need to return to work shortly after giving birth (less than 24 weeks), in contrast to women in higher-income countries [14].

For example, a study examining the attitudes and practices of EBF among bankers in Nigeria’s commercial capital found that although 90% of respondents had a positive attitude towards EBF six months post-delivery, only about 29% actually practised it, and 56% started but could not sustain it [15]. A significant factor was the inability to obtain up to six months of maternity leave. Most sub-Saharan African countries provide only between 8 to 14 weeks of maternity leave, whereas European countries like the UK, Greece, and Bulgaria offer between 39 to 59 weeks [16]. However, some studies suggest that paid employment itself might not be a barrier, as a supportive workplace environment has been shown to facilitate the continuation of breastfeeding [17].

Understanding the knowledge, intention, and practice of EBF is crucial for achieving Sustainable Development Goals (SDGs) 2 and 3, which focus on ending hunger and promoting good health and well-being. It is essential to continuously review and evaluate how women employed in private organizations manage the dual demands of work and EBF, especially in the context of constantly changing economic conditions and increasing work demands. Protecting the health and well-being of both mothers and infants is paramount. By assessing the knowledge, intention, and practice of EBF among this group, the study aims to provide valuable insights into the current landscape. The findings will help identify challenges and opportunities for improving EBF practices, ultimately aiding policymakers in developing strategies that support nursing mothers in balancing their work responsibilities with the vital task of breastfeeding. Obtaining such data is key to understanding how best to support employed nursing mothers and ensure the health and well-being of their infants. Thus, this study assessed the knowledge, intention and practice of EBF among Privately Employed Nursing Mothers in Ibadan Metropolis.

2. Methods

2.1. Study Design, Location, Population, and Sampling

This study employed a cross-sectional survey design to assess exclusive breastfeeding practices among nursing mothers. The study was conducted in the metropolitan area of Ibadan, Oyo State, Nigeria. The study population comprised nursing mothers employed in private schools, banks, and private hospitals within the urban centers of Ibadan.

A convenience sampling technique was adopted to recruit 250 respondents used in this study. The inclusion criteria comprised nursing mothers employed in private organizations in Ibadan who had at least one living child aged 24 months or younger. The private organizations included those in banking (30), educational (58), organized firm (75), and company/factory (87).

2.2. Data Collection

Data for the study were collected using a self-administered questionnaire adapted from previous related studies [15] [18]. The questionnaire was distributed to participants within the selected private organizations. Prior to data collection, the purpose of the study was explained orally to each participant, and informed consent was obtained. Detailed instructions on how to complete the questionnaire were provided to ensure clarity and accuracy. Participants were then given the questionnaires to complete at their convenience.

2.3. Method of Data Analysis

Data analysis was conducted using the Statistical Package for the Social Sciences (SPSS) version 21. Frequency and proportion were used to describe the study, while the chi-square test was used to determine associations between categorical variables, with a significance level set at p ≤ 0.05. Multivariate analysis was performed to explore the relationships between variables, and logistic regression was utilized to identify factors influencing the practice of exclusive breastfeeding among employed nursing mothers. Exclusive breastfeeding was measured using mothers’ self-reports regarding whether they exclusively breastfed their infants during the first six months. Knowledge of exclusive breastfeeding was assessed using a set of eight questions. Each correct response was awarded a score of 1, while each incorrect response received a score of 0. The total score for each respondent was converted to a percentage and categorized into three knowledge levels: poor knowledge (0% - 49.9%), fair knowledge (50% - 74.9%), and good knowledge (75% and above).

2.4. Ethical Consideration

Ethical approval for this study was obtained from the Federal Ministry of Health Research Committee, Oyo State, with reference number AD13/479/44576. Participants were thoroughly informed about the study objectives and the significance of the findings. Voluntary informed written consent was obtained from all participants prior to their involvement in the study. Confidentiality of the collected information was strictly maintained throughout the research process. Only the researcher, research assistants, and data analyst had access to the data. To ensure privacy and anonymity, the names of the respondents were not included in the questionnaires.

3. Results

Table 1 shows the percentage distribution of respondents according to their background characteristics. The majority (42.8%) of the respondents were between the ages of 30 - 34 years, while 26.4% were older than 34 years. Additionally, most respondents (87.6%) were Christians, with the remaining being Muslims. The majority (96.4%) of the respondents belonged to the Yoruba ethnic group. It was also revealed that 96.4% of the respondents were married, and the vast majority (98.8%) had post-secondary education. In terms of employment, 34.8% of the respondents were working in the educational sector, while only 12.0% were employed in the banking sector. Furthermore, 40% of the respondents worked 8 hours per day, and another 40% worked 9 - 13 hours per day.

Table 1. Percentage distribution of respondents according to background characteristics.

Concerning the respondents’ awareness of EBF, about 60% of the respondents heard about EBF through health workers, while 9.2% heard through television, 6.4% from relatives, and 5.6% through the radio. Figure 1 shows the other sources of information highlighted by the respondents.

The knowledge score of EBF among privately employed nursing mothers depicted that the majority (74.5%) of the respondents had good knowledge of EBF, while 25.5% had poor knowledge about EBF. However, over 70% of the respondents erroneously believed a nursing mother should not attempt to breastfeed if she delivered via caesarean section, while over 50% believed that breast milk was only required for 3 months, after which baby formula could be introduced, while about 26% of the respondents erroneously believed a nursing mother should not attempt to breastfeed if she delivered via caesarean section. Other significant erroneous beliefs shared by a significant portion of the respondents were that feeding infants with formula milk increases their immunity (64%) and that nursing mothers who plan to return to work sometime after delivery should not attempt practising EBF (32%). On the other hand, over 90% of the respondents were rightly aware that the best food for newborns is breast milk only and that breastfeeding enhances bonding between mother and child. Moreover, over 70% were aware that babies exclusively breastfed had increased immunity and that babies fed exclusively with milk do not require water and other meals within the first 6 months. A detailed account of the knowledge questions and their responses are highlighted in Table 2.

Figure 1. Percentage distribution of respondent’s source of information.

Table 2. Knowledge of exclusive breastfeeding among employed nursing mothers.

In addition, when assessing the willingness of working-nursing mothers to engage in EBF for 6 months, 78.8% of the respondents intended to practice EBF for six months, but only 51.2% actually practised it for 6 months. The major hindrances reported by the respondents were short maternal leave period (55.7%), insufficient breast milk production (18%), lack of social support (11.5%), lack of friendly workplace (9.8%), and baby’s refusal to be breastfed (4.9%).

Table 3 shows the factors associated with the practice of EBF for six months. Although the result showed that there is no significant association between the age of the respondents and the practice of EBF, the practice of EBF rises with an increase in age. Respondents aged < 30 were 40% and aged 30 - 34 were 22% less likely to practice exclusive breastfeeding compared to those aged > 34 years (AOR = 0.60; 95% CI 0.26 - 1.41) and (AOR = 0.78; 95% CI 0.36 - 1.70) (Table 4).

Table 3. Factors associated with the practice of exclusive breastfeeding for six months.

Boldened values represent associations with statistically significant differences.

Table 4. Factors influencing the practice of exclusive breastfeeding for six months.

Boldened values represent associations with statistically significant differences. UOR- Unadjusted Odds Ratio; AOR- Adjusted Odds Ratio.

Surprisingly, the respondents who had poor knowledge were 4.99 times more likely to practice EBF than those with good knowledge (AOR = 4.99; 95% CI 2.22 - 11.23). Respondents who did not have a partner’s support on EBF were 20.95 less likely to practice exclusive breastfeeding than those who had a partner’s support at (AOR = 20.95; 95% CI 5.07 - 86.49). Respondents who agreed that breastfeeding distracts workers at work are 61% times less likely to practice EBF than those who disagree on it (AOR = 0.39 95% CI 0.19 - 0.79). Respondents who did not go for antenatal care are 1.08 more likely not to practice EBF than those who go for the antenatal clinic at (AOR = 1.09 95% CI 0.56 - 2.09). Results also show that respondents who had difficulties with breastfeeding their babies in the early days were 2.90 times less likely to practice EBF than those who did not have difficulties in their early days (AOR = 0.34 95% CI 0.16 - 0.73). Finally, the result showed that respondents who did not have a friendly environment were 20.50 times less likely to practice exclusive breastfeeding than those who had a friendly environment at work (AOR = 20.50 95% CI 2.31 - 182.28)

4. Discussion

The broad objective of this study was to assess the knowledge, intention, and practice of EBF among employed nursing mothers working in private organisations in Ibadan Metropolis. The socio-demographic information reported in this study showed that almost all the respondents were married, and the majority were over 30 years of age with a tertiary educational level. These socio-demographic information are similar to the studies carried out in Ogun State and F.C.T, Abuja [19] [20].

The finding of this study showed that more than half of the respondents were reported to have heard about exclusive breastfeeding through health workers. This implies that they received correct information with regard to optimal breastfeeding practices during their antenatal visit and could be why knowledge level was quite high. This finding is consistent with the result of the research conducted in F.C.T Abuja [20]. Also, the findings of this study revealed that close to three-quarters of the respondents had good knowledge of EBF. This is in contrast to findings from a study in Sokoto, Northern Nigeria, where less than one-third of respondents had adequate knowledge [21]. The difference in knowledge of EBF is most likely because of the educational status of the women; in this study, a majority had attained tertiary education, as opposed to only 5% in the other study. This is consistent with other literature that has reported the existence of an educational gap between the Southwest where this study was conducted, and Northwest Nigeria [22]. Thus, this indicates more EBF community education campaigns are required in Northern Nigeria in a bit to raise awareness and bridge existing gaps.

It is typically expected, and as has been reported from previous studies, that maternal knowledge about breastfeeding would positively influence the prevalence of successful breastfeeding [18] [23]. However, the finding of this study revealed that the practice of exclusive breastfeeding was low compared to others with similarly high knowledge of breastfeeding. Several explanations may account for this unexpected association. First, mothers with lower formal knowledge may still be strongly influenced by cultural norms, family pressure, or traditional beliefs that promote exclusive breastfeeding, independent of formal health education. Secondly, confounding factors, such as higher social support, lower employment pressures, or reduced exposure to alternative feeding options, may have contributed to this pattern. Also, this finding could be attributed to peculiar barriers associated with working mothers, such as short maternal leave and a lack of a friendly environment at the workplace. Similar barriers have also been reported in related studies among working-nursing mothers conducted in Lagos, Nigeria and Ghana [15] [24]. This is also corroborated by the fact that more than three-quarters of the respondents in this study had the intention to breastfeed their babies exclusively for six months, but only half of the women eventually practised EBF for six months. This finding is comparable to the study that was carried out among employed nursing mothers in other local, regional, and international studies [12] [18] [25].

Furthermore, results from a study conducted in Shanghai indicated that Shanghai women having a paid maternity leave of more than 120 days was positively associated with exclusive breastfeeding, which further supports the idea that maternity leave policies are effective at increasing exclusive breastfeeding [26]. In contrast to this, most sub-Saharan African countries provide only between 56 to 98 maternity leave, with Nigeria on the lower end of the spectrum [16]. The positive impact of increasing paid maternity leave duration on the practice of EBF was clearly shown in a study that examined 38 low-income and middle-income countries (LMICs) [27]. It was revealed that a 30-day increase in the paid maternity leave duration translated to a 7.4% increase in the prevalence of early initiation breastfeeding, a 6% increase in EBF, and an increase in breastfeeding duration by 2.2 months [27]. This posits that increasing the prevalence of EBF requires significant legislative support. Governments are tasked with creating laws (such as extending paid maternity leave) that will empower nursing mothers to safely practice EBF without the fear of career or financial reprimand. The gains potentially derived from such policies will yield substantial social and economic gains as infant mortality and morbidity are expected to reduce significantly [28]. It has been estimated that optimal breastfeeding could reduce child mortality by about 800,000 in low-income settings [29].

Another key barrier to practising EBF identified by the respondents was unfriendly work environment. Studies have reported that the provision of private lactation rooms, breastfeeding and breastmilk extraction breaks, and nursery facilities close to the workplace will significantly improve the ability of nursing mothers to engage in optimal breastfeeding practices [30]. In fact, the International Labour Organization (ILO) has recommended all places of work should be breastfeeding-friendly, implying a workplace should have “comfortable, private space to express breast milk, access to a fridge to store it, a clean and safe environment, as well as day-care facilities and family-friendly working time arrangements for both women and men” [31]. The gains from such supportive workplace policies were clearly seen in an intervention study conducted in Kenya [32]. The nursing mothers with supportive workplace breastfeeding policies (such as breaks, creches, lactation centres and milk storage spaces) had an 81% prevalence of EBF compared to a 20% prevalence among nursing mothers with no workplace support [32]. Thus, it is highly recommended that relevant local and international regulatory agencies provide adequate oversight to ensure companies are structured to provide an enabling environment to support nursing mothers.

Finally, results from this study indicated that having a supportive partner and other social support positively contributed to the effective practice of EBF. This is in tandem with findings from a study carried out in Bangladesh, which reported that the partner is a very important source of emotional support that positively stimulates and gives confidence and the will to prolong breastfeeding [33]. In another study, social support was significantly linked with longer breastfeeding duration [34]. This indicates that increasing EBF practice is a holistic effort that involves every arm of society. To this end, campaigns should not only target pregnant women and nursing mothers but should also target other members of society at large.

5. Conclusion

This study aimed to assess the knowledge, intention, and practice of exclusive breastfeeding (EBF) among employed nursing mothers in private organizations in Ibadan Metropolis. The findings revealed that while the majority of respondents had good knowledge of EBF, and a high proportion intended to practice it, actual adherence to EBF for the recommended six months was significantly lower. Key barriers identified included short maternity leave, an unfriendly work environment, and a lack of social support. These results suggest the need for targeted policies and workplace interventions to support nursing mothers. Recommendations include extending maternity leave, creating breastfeeding-friendly workplaces with appropriate facilities, and promoting social support networks. Addressing these factors is essential to enhance EBF practices, which can significantly reduce child mortality and morbidity, aligning with the goals of improving maternal and child health.

6. Study Limitations

This study has some important limitations that should be acknowledged. First, the extremely large adjusted odds ratios observed for some associations may indicate potential issues such as sparse data, residual confounding, or model instability.

Ethical Approval

Ethical approval for this study was obtained from the Federal Ministry of Health Research Committee, Oyo State, with reference number AD13/479/44576.

Consent to Participate

Informed consent was obtained from every study participant.

Consent for Publication

All authors consent to the publication of this paper. No identifiable information from respondents is embedded.

Data Availability

Data is available upon reasonable request to the corresponding author.

Authors Contributions

TAO and AIO conceptualized the research; TAO and AIO drafted a proposal for ethical approval; AIO was responsible for data collection; TAO and AIO handled data management and d analysis; AIO wrote the first draft; TAO, JVI revised the manuscript; JVI was responsible for data visualization.

Acknowledgement

The contributions of Dr. Wada Ojima Zechariah and Dr. Olawade David Bamidele in the data management, analysis and revision of the manuscript are highly appreciated.

Conflicts of Interest

The authors declare no conflicts of interest regarding the publication of this paper.

References