The Associated Factors Hampering Mothers towards Exclusive Breastfeeding EBF through Knowledge, Attitude and Practice (KAP) Studies at Al-Sabah Children Hospital /Juba -South Sudan

Introduction: Exclusive breastfeeding EBF is the feeding of an infant entirely with breast milk (i.e. via lactation). EBF is an important public health strategy for improving infant and child morbidity and mortality indicators, The World Health Organization (WHO) &(UNICEF) recommend exclusively breastfeeding for the first 6months of life, EBF, improves the growth, and survival status of newborns and is best forms of prevention. Goals: To assess the related factors hindering mothers knowledge, attitude and practices towards exclusive breast feeding of infants in Juba. Methodology: Study design & area: A questionnaire-based qualitative study was conducted on a group of 123 nursing mothers from December 2013 to 30th June 2014 to evaluate knowledge attitude and practices towards EBF, The sample size was selected randomly at AL-Sabah Hospital. Results: age range 54.5


Introduction and Literature Review
Exclusive Breastfeeding EBF is the feeding of an infant or young child with breast milk directly from the mother's breast (i.e. via lactation) rather than using infant formula. It is an important public health strategy for improving infant and child morbidity and mortality, as well as maternal morbidity and helping to control health care costs [1] with the exception of oral rehydration solution, drops or syrups consisting of vitamins, minerals supplements or medicine. Historically, abandonment of breastfeeding began in higher socioeconomic level followed by a decrease in lower socioeconomic levels. As the trend was reversed, women in the upper socioeconomic levels were the first to show an increased incidence of breast feeding followed by progression down class line. A significant boost to breastfeeding came from the American Academy of Pediatrics (AAP), which in 1978 recommended that all Physicians encourage mothers to breast their babies. The World Health Organization (WHO) and United Nations Children's Fund (UNI-CEF) recommend that every infant should be exclusively breastfed for the first six months of life, with breastfeeding continuing for up to two years of age or longer. Exclusive Breastfeeding (EBF) for the first 6 months of life improves the growth, health and survival status of newborns [2]. And EBF is one of the most natural and best forms of preventive medicine. EBF plays a pivotal role in determining the optimal health and development of infants, and is associated with a decreased risk for many early life diseases and conditions, including otitis media, respiratory tract infection, Diarrhea and early childhood obesity [3].
It is estimated that sub-optimal breastfeeding, especially non-exclusive breastfeeding in the first 6 months of life, results in 1.4 million deaths and 10% of the disease burden in children younger than 5 years of age [4]. EBF reduces infant mortality rates by up to 13% in low-income countries [5]. Some African countries like Nigeria and Ghana have established the Baby-Friendly Hospital Initiative (BFHI) with the aim of providing mothers and their infants a supportive environment for breastfeeding and to promote appropriate breastfeeding practices, thus helping to reduce infant morbidity and mortality rates [6].
Numerous variables may influence breastfeeding such as race, politics, maternal age, maternal employment, level of education of parents, socio-economic status, insufficient milk supply, infant health problems, maternal obesity, smoking, parity, method of delivery, maternal interest and other related factors, Some researchers have proposed that lack of suitable facilities outside of the home, inconveniences; conflicts at work, family pressure and ignorance adversely affect the willingness of women to practice EBF [7].The need to return to work has also been implicated as a factor interfering with EBF [8]. In late 1900s Breastfeeding was discovered to have unrecognized emotional and health benefits for baby and mothers [9] also contains all the nutrients that an infant needs in the first 6 months of life, including fat, carbohydrates, proteins, vitamins, minerals and water [10,11]. It is easily digested and efficiently used. Breast milk also contains bioactive factors that augment the infant's immature immune system, providing protection against infection, and other factors that help digestion and absorption of nutrients. Powdered infant formula it may be unsafe in other ways. Life threatening infections in newborns have been traced to contamination with pathogenic bacteria, such as Entero bacterial sakazakii, found in powdered formula [12]. Soy formula contains phyto-oestrogens, with activity similar to the human hormone Oestrogen, which could potentially reduce fertility in boys and bring early puberty in girls when the oxytocin reflex is active, there for breastfeeding helps prevent growth faltering and stunting, particularly as it reduces the risk of illnesses [13]. Breastfeeding protects against weight loss due to diarrhea, and in some studies children exclusively breastfed were shown to be less likely to be stunted [14]. Due to its large impact on reduction of infectious diseases, breastfeeding plays a role in reduction of stunting, as infectious diseases are important determinants of stunting. However, breastfed children will still become stunted if they do not receive an adequate quantity and quality of complementary foods from the age of six months onwards [15]. A more detailed understanding of the attitude of mothers to EBF and their knowledge of the importance of breastfeeding in South Sudan is needed to develop effective interventions to improve the rates of EBF and thus reduce infant mortality rate that is the highest in the World.

Scope of the problem
Data suggest that infant mortality in developing countries is 5-10 times higher among children who have not been breastfed or who have been breastfed for less than six months. It is estimated that some optimal breastfeeding especially non-exclusive breastfeeding in the first six months of live results in 1.4 Million deaths and 10% of disease burden in children younger than five years [16]. The Global Strategy for Infant and Young Child Feeding, according to WHO, two-thirds of under-five deaths that occur in infancy are mostly related to poor feeding practices. Globally, less than 40% of infants under six months of age are exclusively breastfed, despite the well documented benefits of breastfeeding [17]. In developing countries only 38% of infants aged less than six months are exclusively breastfed [18]. According to the 2010 Sudan household survey only 45% of the babies in Southern Sudan are exclusively breastfed for the first six months of life. On a press report released by UNCIEF on the breastfeeding week, 1-7, August 2013, they said most mothers in South Sudan do not breastfeed their children exclusively because of inadequate information on the importance of early initiation and EBF, inadequate support from families and communities, lack of counseling to new mothers on breastfeeding and heavy workload that keeps them away from their children for long hours [19].

Statement of the problem
One of the biggest threats to infant feeding is complacency. With competing priorities, disease specific funding, and interest in technologies, campaigns and products, the attention breastfeeding receives is very small, given the magnitude of the problem and the potential impact. Working mothers are kept away from their children by the schedules of their long working hours and hence have limited time to nurture their babies properly aggravate poor attitude towards breastfeeding. Breastfeeding has economic benefits, is also the least expensive. For many poor households, the high cost of breast milk substitutes, feeding and sterilizing equipment, fuel, represents a drain on scarce household resources. Plus cost of health care for the sick infant.

Justification for the Study
The study is being conducted to encourage and influence the attitude of EBF practices which count on awareness on importance of EBF, breast milk is the adequate 'baby food' that contains sufficient nutritional contents necessary for the growing of healthy babies, non-practice of EBF complicate the healthy growth of infants.
Goal: To ensure that every mother in South Sudan value the importance of EBF for the optimal growth, survival and development of healthy infants.
General Objective: To assess the related factors hindering mother's knowledge, attitude and practices towards exclusive breastfeeding of infants in Juba.

Specific Aims:
To determine the prevalence of EBF in Juba / South Sudan. • To evaluate pattern of Exclusive Breastfeeding (EBF) among • lactating mothers attending Al-Sabah Children Hospital.
To compare exclusive breastfeeding between working and • non-working mothers.
To identify the major problems hindering EBF among the • study group.
To identify the relationship between the age of mother and the • attitude to breastfeeding of infants.

Research hypothesis
Educated mothers tend to exclusively breastfeed their infants • more than the uneducated mothers.
Mothers who attend ANC are more likely to exclusively • breastfeed compared to those who do not attend.
Elderly Mothers exclusively breastfeed Infants more than • young breastfeeding mothers in Juba.

Study design and data collection
A questionnaire-based qualitative study was conducted on a group of 123 nursing mothers from December 2013 to 30th June 2014 to elicit information about knowledge attitude and practice towards EBF by using a properly designed questionnaire given to Breastfeeding mothers at Al-Sabah children Hospital in Juba.

Study Area
Al-Sabbah Children Hospital was established in 1983-1984 through the support of Kuwait government to the people of Southern Region (former Sudan). It is located opposite All Saints Cathedral on the way from Juba Teaching Hospital on the right side after Mobil roundabout. The Hospital was under the administration of the Islamic Organization until 2005, when the management was handed over to Central Equatoria Government (CEG). The hospital is made up of five departments with five medical officers. It daily receives 100-150 outpatients at the Clinic because it is the only Children Hospital in Juba County and has inpatient capacity of one hundred (100) m beds only.

Population, Sample size and Sampling technique
The sample size was one hundred and twenty-three (123) participants selected randomly from the population of breastfeeding mothers attending clinics at the Hospital. These mothers come from different Payams (Districts) of Juba County.

The Duration of Study
December 2013 to 30th June 2014.

Questionnaire design:
The questionnaire consisted primarily of closed and open ended questions format and multiple responses for ease of completion and analysis. A structured questionnaire was self-administered by literate mothers and interviewer-administered for those who were illiterate. The resulting questionnaire consisted of 25 questions, categorized on two sections: Background information on the mother's demography that in-• cludes age, Education, marital status, occupation, residence, Religion, chronic illness, ANC visits.
Background of the child which includes sex, date of birth (age), • other children<2years and elderly people at home, whether mothers breastfeeds or not and why not? commencement of other foods, breastfeeding initiation, duration of EBF, attitude on EBF sum of time spent on breastfeeding and breastfeeding interference with work productivity, breastfeeding in public places, and immunity.
The subjects: The sample of the nursing mothers' population consisting of mothers aged 16 to above 45 years who were nursing their infants six months and below participated in the study.

Inclusion and exclusion criteria
Inclusion criteria; mothers who have already delivered their • baby and the child is between 0-6 month of age were considered in this study.
Exclusion Criteria: Pregnant mothers or mothers with children • who are above six months of age.

Data Analysis
The questionnaire responses were collected and analyzed using Statistical Package for Social Scientist (SPSS) version 16.0. Chi-square tests were used to evaluate relationship between different selected variables (e.g. find association between level of education and EBF, Age of mother and attitude to EBF). The critical value for significance was set at P<0.05 for all analyses. The findings were presented in tables and pie charts.

Ethical Considerations
Researchers were granted approval by the University of Juba, Department of Community Medicine, and prior consents were obtained from the Hospital Chief Executive Officer (CEO) and all participants who took part in the study.

Results
According to the study, 54.5% of breastfeeding mothers were in the age range 16-25, 40.7% of the mothers were of age range 26-35yrs and finally 4% were in the range 36-45yrs as shown in the ( Based on the educational level 38.2% attended basic education, 19.5% attended secondary, 7.3% attended university and 35% never attend any formal education in average 65% of the breastfeeding mothers attended formal education (   Exploring the income of the study group, the study reveals that 8.1% were self-employed, 12.2% employed both in private and public sector, 79.7% were unemployed (   In context of the religion, majority about 93.5% were Christian, 5.7% were Muslim and 0.8% were non none religious (   In regards to ANC visits it shows that 77.2% regularly attended, 11.4% irregularly attended, 10.6% of no ANC attended, and 0.8% do not know (    Immunization status of the infant; the finding reveal that, majority 80.5% were immunized with 19.5% of the infant not given any vaccine (  Having dependent or other people at the home; it was found that 16.3% had other infants at their homes, 19.5% of the respondents had children of less than two years of age at their home, 21.1% had adults greater than sixty years old and 43.1% had no any other departments in their homes (   For those who were breastfeeding, 59.3%were breastfed 8 times or more. 11.8% breastfed less than 8 times, 26.0% do not know the number of times they breastfeed their infant and 3.3% were not breastfeed (

Reasons for not Breastfeeding
The following were the reasons given by the mothers of the 3.3% of infants who were not breastfeed; abandonment by the mother (0.8%), breast lump(swelling)0.8%, no enough milk(0.8%), and oral candidiasis (0.8%) (  According to our finding 30.1% of the infants were breastfed 2-10 times, 15.4% were breastfed 11-20 times, 51.2% do not know the number of times their infant breastfed and finally 3.3% were not breastfed completely (

Initiation of Complementary Foods
In 22.8% of the infants their mothers introduced complementary food before four months, 37.4% between four and six months, 30.9% after six months and 8.9% do not know when to start giving complementary food (

Start of Breastfeeding
The knowledge of mothers about the initiation time for breastfeeding was tested and the responses were as follows; 66.2% immediately after birth, 20.3% within hours, 13.8% within days and 3.3% do not know the time for initiation of breastfeeding ( Table

Duration of EBF
Responses to the participants' knowledge were 17.1% first three months, 67.5% first six months, 8.1% up-to two years and 7.3% do not know for how long the exclusivity of breastfeeding should be practiced (

Attitude of Respondent to EBF
Agree 85.4% to EBF, 8.1% were uncertain and 6.5% disagree with exclusive breastfeeding (  Time spent breastfeeding and its interference with work productivity: 27.6% of the women agree that time spent breastfeeding at work should not be paid but 73.4% disagree with not paying the time the mother spent breastfeeding at work place (

Whether Breastfeeding interferes with work Productivity
44.7% of the women consented that breastfeeding or expressing breast milk at work will interfere with work productivity while 55.3% said this practice does not interfere with work productivity at all (  Breastfeeding in public places: 65% of the mothers agree that the baby can be fed anywhere whenever it feels hungry, 8.1% were uncertain and 39.0% disagree with breastfeeding their baby in public places (    Antenatal Care (ANC) correlation with exclusive breastfeeding: Regularly attended 25.2%, irregularly attended 6.5%, No ANC attended 2.4%, and 0.8% of the mothers who do not know ANC exclusively breastfed (Table 27)

ANC Visits
Other fluids given/24hours

Discussion
This study aimed to determine the prevalence of exclusive breastfeeding, knowledge, and attitude and associated factors affecting it. Ninety-seven percent of the mothers were practicing breastfeeding with only three percent who had not breastfed because of breast swelling, oral Candidiasis, scars breast milk and abandonment by the mother. This study revealed that the prevalence of exclusive breastfeeding practice for infant in their first six months of life was thirty-five percent(35%), this finding is lower than the 2010 Sudan household survey which found out that forty-five percent of the babies in Southern Sudan were exclusively breastfed [19]. Our finding is much higher than in Lebanon (10%), almost equal to Bangladesh (36%) and lower than the exclusive breastfeeding prevalence in Ethiopia (49%) (51,52). This decline in the trend of exclusive breastfeeding blamed is on the mothers not adhering strictly to the World Health Organization recommendation of EBF for the first six months. In addition to socio-cultural practices of early introduction of water, infant formula, soup, porridge and others before six months of age. This is confounded by misleading advertisement of formula milk in the market which might have contributed negatively to exclusive breastfeeding. Although 67.5% of the participants had adequate knowledge on the definition of EBF, the practice was relatively lower (35.0%) compared to the WHO recommendations for exclusive breastfeeding in developing countries. The average knowledge of the respondents about exclusive breastfeeding is about seventy-six (76%).Our study participants highly valued the immune benefits of breastfeeding 97.6%. It was found out that majority of the respondents had positive attitude towards exclusive breastfeeding (85.4%) but only 33.4% of them exclusively breastfed.
We found that those participants who were mixed or formula feeding were more likely to have negative attitudes towards breastfeeding (13.6%), including thinking that breastfeeding was embarrassing and difficult in public Places (39%), it may be difficult if someone else feeds/cares for the child, and physically painful and uncomfortable and were likely to be influenced by the negative attitudes of family members or friends. Other studies that have evaluated the relationship between attitudes towards breastfeeding and breastfeeding intention have found that partner or friend/family support is important as is confidence or prior experience and fear of pain in deciding not to breastfeed. Mothers between the ages group 16-25 years showed the highest percentage (17.9%) of exclusive breastfeeding in this study which was significantly ( p<0.05) different from mothers in the age group 26-35 years ( 16.3%) and age group 35-45 ( 0.8 % ).This finding disapproved our third research hypothesis " elderly mothers were more likely to exclusively breastfeed compared to young mothers, this may be attributed to higher frequency registered in this age group, in addition to good advices given by grandmothers who are perceived to be key decision makers when it comes to good parenting. Maternal literacy (25.2%) was observed to favor exclusive breastfeeding significantly (p<0.05) was compare to illiterate mothers (9.8%). This may be due to their understanding of the health implication of exclusive breastfeeding on infant's health. This is in the support of the finding in Job, Plateau state Nigeria [20].
Our finding is contrary to the result obtained from Ethiopian demographic health survey, which indicated a declining trend of exclusive breastfeeding with the higher maternal education status [21]. This study has indicated a significant difference among employed mothers (6.5%) with unemployed mothers (28.5%) with regard to exclusive breastfeeding. It also revealed that unemployment is a predication of exclusive breastfeeding which is consistent with the finding of the case study done in Wad Medani Sudan [22]. This might be explaining by the fact of less maternity leave (two month after delivery in our context), which makes employed mothers to have less opportunity to stay at home, compromising exclusive breastfeeding. Mothers also may have to leave their babies to search for a job. These finding calls for course of action to initiate breastfeeding friendly working environment, as well as the extension of maternity leave to encourage mothers to exclusively breastfeed their babies to improve child health outcome.
Our study shows that the religion of mothers exclusively breastfeeds, with the majority about 93.5% were Christian, 5.7% were Muslim and 0.8% were not practicing specific Creed, this need farther investigation how the Religion may affect EBF? This current study showed that mothers who do not have chronic illness constitutes (91.9%) out of which a third (32.5%) exclusively breastfed compared to 8.1% of those mothers who had chronic illnesses, and thy undergoing decline of breast milk production due to the stress of illness and might be due to medical advice causing them to opt for mixed feeding. The current study showed that the Attendance of Antenatal Care (ANC) clinic (88.6%) enhanced mothers' knowledge and appreciation of the demands and benefits of exclusive breastfeeding, and empowers them to resist external interferences and pressures. Out of the above percent about a third (31.7%) exclusively breastfed, this could be due to the health Education about exclusive breastfeeding they received on their ANC visits. Though majority of the mothers attended ANC at least eight percent of them did not had their infants immunized. According to our finding as the age of the infant approached six months, the rate of exclusive breastfeeding decreased significantly, which is similar to other studies done in Uganda, Sudan and Ethiopia [21][22][23]. This might be due to the fact that postpartum care is traditionally given in the first few months after birth where mothers remain at home, creating a chance to exclusively breastfeed their infants. The other possible reason is that the mother might have introduced complementary feeds for their infant's due to the assumption that breast milk alone could not satisfy their needs as the infant gets older. as the age of the child increases the rate of exclusive breastfeeding decreases as explained by the short birth interval since some mothers had other children of less than two years at home. There was an association between presence of other dependents (elders and toddlers) at home and exclusive breastfeeding, mothers not having other dependents (15.4%) have higher rate of exclusive breastfeeding compared to those who had other dependents (13.8%); This could be due to competition for the available resources at home, overworking of the mothers leading to reduced breast milk production as a result complementary foods are introduced early.

Strengths and Limitations
The use of validated questionnaires, quantitative method of data collection is the strengths of this study. However, the 24-hour recall determining exclusive breastfeeding practice means some infants who were given other liquids regularly may not have received them in the last 24 hours before the interview, which may cause overestimation of the proportion exclusively breastfed. Similarly, Children who have not been receiving other fluids regularly but had been given liquid in the past 24-hour recall method can underestimate the actual EBF rate in the population studied.
Several authors have questioned the validity of the 24-hour recall method [23]. The major criticism of the 24-hour recall method is that it misclassifies too many mothers as exclusively breastfeeding; a proportion of mothers may be providing substances other than breast milk on an irregular, not daily, basis. Many studies have shown that a large proportion of infants who were exclusively breastfed in the previous 24-hours were either not exclusively breastfed during the previous seven days, and/or, not exclusively breastfed since birth [23] Median duration can also be affected by maternal recall, which might be prone to recall and social desirability bias. Therefore, readers are recommended to take this into account during interpretation of these findings. In addition, there are also some variables that were not significantly associated (how-ever known in several studies) with the outcome of interest which might affect the precision. This might be due to the sample size, which might not be adequate to justify the relationships between the explanatory variables and outcome of interest. Therefore, any interpretation of this finding should take into account.

Conclusions & Recommendations
Based on the findings, breastfeeding mothers are faced with multiple challenges as they struggle to practice exclusive breastfeeding. Thus, scaling up of EBF among mothers requires concerted efforts and adequate support at the all levels of South Sudanese Society. The promotion and acceptance of the practice is important in South Sudan where there is high level of poverty, disease burden and low access to clean water and good sanitation. The importance of availability and accessibility of Ante Natal Clinic ANC, training of Healthcare workers and counseling mothers are crucial, also targeting influential members of the family for proper EBF practices and the adoption and implementation of the WHO/UNICEF Global strategy for infants and young child feeding (IYCF) at all healthcare levels in the States of the Republic of South Sudan is paramount to promote the growth, survival and health of infants.