Knowledge, attitudes and practices of Iraqi mothers and family child-caring women regarding breastfeeding.

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A.J. Abdul Ameer,¹ A-H.M. Al-Hadi¹ and M.M. Abdulla¹

ABSTRACT We assessed breastfeeding knowledge, attitudes and practices of 3413 Iraqi mothers and adult female relatives in the same household and their association with sociodemographic characteristics. The majority of the women (73.1%) initiated breastfeeding early after delivery, 92.9% believed colostrum was good for their baby and 64.6% breastfed on demand. However, knowledge was lacking about full exclusive breastfeeding until 6 months postpartum, signs of good positioning and latch-on and the correct time to introduce supplements. Nearly 35% believed that breast milk was not enough for their infants. Rural and less educated women knew less about breastfeeding concepts than more educated urban women but more continued breastfeeding longer and introduced supplements later.

Connaissances, attitudes et pratiques en matière d’allaitement au sein des mères de famille iraquiennes et de leurs parentes s’occupant des enfants

RÉSUMÉ Nous avons évalué les connaissances, les attitudes et les pratiques en matière d’allaitement au sein de 3413 mères iraquiennes et femmes de la famille s’occupant des enfants, ainsi que leur association avec les caractéristiques socio-démographiques. La majorité des femmes (73,1 %) commençaient à allaiter peu de temps après l’accouchement, 92,9 % pensaient que le colostrum était bon pour leur bébé et 64,6 % allaitaient à la demande. En revanche, on observait un manque de connaissances sur l’allaitement exclusif au sein jusqu’à six mois après l’accouchement, sur les signes attestant d’une bonne position et d’une bonne préhension et sur le moment opportun pour introduire des compléments dans l’alimentation du bébé. Près de 35 % des femmes pensaient que le lait maternel n’était pas suffisant pour leur nourrisson. Les femmes vivant dans les zones rurales et ayant un faible niveau d’instruction avaient moins de connaissances sur les concepts relatifs à l’allaitement au sein que les femmes plus instruites vivant en milieu rubain, mais elles étaient plus nombreuses à allaiter plus longtemps et à attendre avant d’introduire des compléments alimentaires.

¹Department of Community Medicine, College of Medicine, Al-Nahrain University, Baghdad, Iraq (Correspondence to A.J. Abdul Ameer: This email address is being protected from spambots. You need JavaScript enabled to view it.).
Received: 17/01/06; accepted: 25/06/06
EMHJ, 2008, 14(5): 1003-1014 

Introduction

Breast milk contains all the nutrients, antibodies, hormones and immune factors that a baby needs. On 18 May 2001, the World Health Organization (WHO) endorsed exclusive breastfeeding (BF) until an infant is 6 months of age [1]. If the drive for universal BF in the first 6 months is accomplished, an estimated 1.5 million lives could be saved each year [2].

The United Nations Children’s Fund (UNICEF) has called for greater global commitment to promote BF [2]. In some countries of the Middle East and North Africa where the advantages of BF have been widely publicized and where the Babyfriendly Hospital Initiative (BFHI) has been implemented, BF rates are increasing. Countries like the Islamic Republic of Iran, Iraq, Jordan, Morocco, Oman, Syrian Arab Republic and the Gulf countries have successfully adopted BF promotion and BFHI since the 1990s [3]. In Iraq, BF is almost universal and regarded as the normal way to feed infants and young children. Although promotion of BF and BFHI began in 1993, there is a lack of data on exclusive BF and factors associated with it, making it difficult to identify areas that require intervention. Moreover, baseline data are generally lacking, making trend assessment difficult.

Over the past 30 years, many studies worldwide have identified the socioeconomic determinants of BF, but far fewer have attempted to explore societal and cultural influences on BF [4]. For a BF intervention to be successful, research needs to be conducted on public perceptions and societal norms that shape women’s decisions to initiate and continue BF [5,6]. Without an understanding of these factors, health care professionals cannot easily develop and implement effective strategies for promoting BF in any population [6–8].

To understand the societal norms and attitudes to BF in Iraq, we used survey interviews to explore some of the factors associated with the beliefs, attitudes and practices of BF of Iraqi women and to assess the effect of urbanization, educational background and age on these views.

Methods

We analysed data from a nationwide crosssectional household survey (KAP-2002, unpublished) conducted by the Ministry of Health, Ministry of Higher Education and the Ministry of Planning and Development Cooperation with support from UNICEF during the period 17 October to 5 November 2002. All the mothers and adult female relatives in the same household (childcaring women) (3413 people) were asked about different factors that may affect their children’s lives including health, nutrition, education, safe water, sanitation and child protection. The BF item was part of the health and nutrition sections, and this article presents the BF findings from the survey.

The families were selected by cluster random sampling with proportional allocation from all Iraqi governorates except the 3 northern ones to which access was prohibited at that time. Both urban and rural areas were included to collect information from a representative sample of Iraqi women.

All the mothers and child-caring women were interviewed by trained interviewers using a pre-tested questionnaire to obtain information on BF knowledge, attitudes and practices and other relevant sociodemographic characteristics. The questionnaire was developed by experts in the ministries of Health, Higher Education, Planning and Culture in Iraq. Permission and ethical approval to carry out the study were obtained from the head of the Central Statistical Organization in Iraq.

Exclusive BF was defined as infant feeding with human milk without the addition of any other liquids or solids. Educational levels of the women were divided into 4 categories: illiterate women or those with informal or unknown education (no formal education), those with primary education (6 years formal education), those with intermediate education (9 years formal education), and those with secondary and higher education (12 years or more formal education).

Analyses were carried out with SPSS, version 11.0. Statistical analysis included descriptive statistics [mean, standard deviation (SD), ratios and frequencies]. The Student t-test and F-test were used to compare the means of different variables, and the standard chi-squared test was used to test for association in categorical variables. P ≤ 0.05 was considered significant.

Results

Table 1 shows the characteristics of the women and their knowledge and practice of BF. The mean age (SD) of the women was 35.3 (9.8) years, with an urban to rural ratio of 1.8:1.0. Only 12.6% of the participants had secondary and higher levels of education.

As regards BF, 73.1% of the women started BF immediately and 92.9% considered giving colostrum was good for the baby; however 60.2% also gave water and sugar early after delivery, especially for jaundiced infants. We found that 88.1% of the women did not wash their hands before starting BF and 64.6% breastfed on demand. Although 1286 (37.7%) of the sample reported that they knew what full exclusive BF was, only 41.8% of these women defined it correctly and 49.5% of these reported that full exclusive BF should continue for 6 months postpartum. Signs of good positioning and latch-on were not clear to all the women and 22.8% did not know any signs.

In addition, 34.8% of the women believed that breast milk was not enough to feed their infants and it is mainly due to mother’s malnourishment (40.3%), unknown causes (22.3%) or due to the mother’s illness (17.8%) (participants could cite more than 1 reason). Thus 78.6% started supplementing BF between 3 and 6 months postpartum (Table 1).

There were statistically significant differences between urban residents and rural residents in all the variables studied concerning KAP about BF (Table 2). Although urban women started BF earlier, more fed according to a schedule and introduced supplements earlier compared with rural women (P < 0.001). Significantly more rural than urban women believed that giving colostrum was not good for the baby, gave water and sugar to jaundiced infants and believed that their breast milk was not enough for their baby (P < 0.001). Also 64.7% of rural women compared with 54.9% of urban women did not know the correct definition of full exclusive BF and its duration (P = 0.001) (Table 2).

A significant association was found between women’s educational level and their knowledge and practice of BF (Table 3). Illiterate women and those with informal or unknown education lacked appropriate knowledge, attitudes and practices of BF compared with urban women in almost all the parameters studied except for the frequency of BF. Significantly more of these women delayed starting BF, believed giving colostrum was bad for the baby, gave water and sugar to jaundiced infants and believed that their breast milk was not enough for their infants compared with more educated women. In addition, fewer washed their hands before BF and knew the correct definition of full exclusive BF and its duration. On the other hand more of illiterate women gave breast milk on demand and delayed introducing supplements than the more educated mothers, more of whom breastfed according to a schedule and started supplements earlier (Table 3).

When the sample was analysed by age group, a statistically significant association was found between age group and some of the variables studied. Younger (≤ 20 years old) women were more likely to start BF later (after the first 24 hours of life) and wash their hands before BF than the other age groups. Also, both younger and older women (≤ 20 and ≥ 41 years) were less knowledgeable of the meaning of full exclusive BF than those aged 21–40 years. However, more older women delayed the introduction of supplements until 6 months postpartum than younger women (Table 4).

Discussion

Because this study was a national survey involving a large, demographically diverse sample of women, the results reflect current social and cultural norms regarding BF in Iraq. Our study shows that many Iraqi women are familiar with the benefits of BF and believe in some important concepts of BF, such as the early initiation of BF, giving colostrum to their babies, and practising BF on demand. On the other hand, these women lacked the knowledge of full exclusive BF, its duration, signs of good positioning and latch on, the need to wash hands before BF and the correct time for the introduction of supplements. The results are generally consistent with the literature and other studies [4,9–14].

As with many other parts of the world, Iraq is experiencing rapid urbanization. An increasingly urban lifestyle can lead to alterations in traditional behaviours such as BF. In addition, evidence shows that maternal education, social class, ethnic background and religion are related to the decision to initiate and continue BF [15]. Results from our study show that urbanization was significantly related to women’s level of education (urban:rural ratio for secondary and higher education level was 12:1). More of these urban, educated women than the rural, less educated women believed and practised correct BF, as for example they started BF earlier, believed in giving colostrum was good for their baby, were more likely to know about full exclusive BF and its duration, and when to start supplements. In addition, fewer would give water and sugar to their jaundiced infants. These beliefs and practices may be the result of the success of BF promotion and BFHI programmes in Iraq. Education influences nutritional knowledge, behaviour, and perceptions toward the child, and women with higher educational levels are more likely to take notice of new information about baby feeding from the media or books. These findings are supported by other studies that showed that mother’s level of education was positively associated with some concepts of BF [5,7–11,13–19].

On the other hand, although exclusive BF of infants for about 6 months and BF with good quality complementary foods up to 2 years are well known recommendations [1,20], most of our participants were not fully aware of this and only 15.7% knew the correct definition of full exclusive BF and its duration. As a result, the vast majority of the women in our sample introduced supplements prior to 6 months of age. A similar rate (86.3%) was reported from a study carried out in Basra, Iraq [21]. This concurs with UNICEF’s report that mixed breastand bottle-feeding as early as the first month and the premature introduction of complementary food are commonly found in all countries in the Middle East and North Africa [3]. Illiterate women and women aged 41 years or older were less likely to practise complementary feeding than younger and more educated women. Many studies have reported similar findings [5,10,13,14,16,22–24].

Concern over inadequate milk production and the belief that breast milk alone is an insufficient source of energy for a growing baby are common among lactating women throughout the world [5,7– 15,17,21,24–26]. In our sample, over a third believed that breast milk was not enough to satisfy their infants, mostly because of the malnourishment of the mother herself. The findings of 2 Iraqi studies, one from Mosul (north) and the other from Basra (south), showed this was the reason for discontinuation of BF in 40.8% and 25.7% of mothers respectively. Although many studies have reported similar findings, most of them simply reported the fear or anxiety of the mother that BF alone may not be sufficient, and not the opinion of the mother about the cause that may contribute to this inadequacy. However, 2 studies reported that inadequate maternal nutrition is a barrier to successful BF [18,27].

A major limitation of our study is its cross-sectional nature. A more detailed comprehensive prospective study or crosscultural research including qualitative methods, such as focus group interviews, would more accurately identify barriers to or promoters of BF among our population and suggest ways of addressing them. Another possible limitation of the data is recall bias, especially in the case of women with older children. However, it is unlikely that recall bias would greatly affect the findings because the survey measured major and memorable life events.

Conclusion and recommendations

Prior to the development of BF promotion programmes there needs to be a clear understanding of what women know, think and practice about BF. This paper provides useful data on BF knowledge, attitudes and practices of a representative sample of Iraqi women and highlights some sociodemographic variables associated with BF initiation and continuation. Our findings also show that the level of exclusive BF was low. Development of successful infant-feeding interventions aimed at promoting overall infant health can benefit from knowledge of these BF patterns. Our findings also support the need for health care system interventions, family interventions and public health education campaigns to promote BF, especially in less educated and rural women.

As health professionals can provide invaluable support for mothers initiating and continuing BF in our population, support for training of government health workers in tertiary, secondary and primary care facilities in lactation management will enable them to promote, support, and protect exclusive BF adequately. Training needs could be extended to staff at private clinics and to traditional birth attendants.

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