Sociodemographic Factors, Breastfeeding Practices and Infant Mortality in Northern Nigeria

TABLE OF CONTENTS

Dedication

Acknowledgement

Table of Content

Abstract

CHAPTER ONE INTRODUCTION
1.1 Background to the Study
1.2 Statement of the Research Problem
1.3 Research Questions
1.4 Objectives of the Study
1.5 Justification for Study

CHAPTER TWO LITERATURE REVIEW
2.1 Meaning and Categorisation of Breastfeeding
2.2 Factors Influencing Breastfeeding Practices among Mothers
2.3 Prevalence of Breastfeeding Practices among Mothers in Nigeria
2.4 Early Breastfeeding Practices among Mothers
2.5.0 The Influence of Socio-Demographic and Economic Factors on Infant Mortality
2.5.1 Educational Attainment versus Economic Status and Infant Mortality
2.5.2 Birth order, Mother’s age at first birth and Infant Mortality
2.5.3 Place of Residence and Infant Mortality
2.6.0 Breastfeeding Practices of Mothers and Infant Mortality
2.6.1 The Influence of Early and Exclusive breastfeeding on Infant’s Health and Mortality
2.7 Environmental Risk Factor and Infant Mortality
2.8.0 Policy Response
2.8.1 National Policy on Infant and Young Child Feeding in Nigeria
2.8.2 The National Policy on Infant and Young Child Feeding in Nigeria (2004 Review)
2.8.3 The Nigeria Child’s Protective Policy
2.9.0 Theoretical Framework
2.9.1 Conceptual Framework
2.10 Study Hypotheses

CHAPTER THREE METHODOLOGY
3.1 Study Area
3.2 Study Design
3.2.1 Secondary Data Source
3.2.2 Qualitative Data Collection and Analysis
3.3 Research Variables
3.4 Data Analysis
3.5 Data Limitations
3.6 Ethical Issues

CHAPTER FOUR DATA ANALYSIS AND INTERPRETATION OF RESULT
4.1 UNIVARIATE ANALYSIS
4.1.1 Distribution of Respondents by Demographic and Socio-Economic Characteristics
4.1.2 Distribution of Respondents by Breastfeeding Practices
4.1.3 Distribution of Respondents by Environmental Risk Factors
4.1.4 Distribution of Respondents by Healthcare Service Utilization
4.1.5 Distribution of Infants by Infanthood Diseases, Treatment and Infant Mortality
4.2 BIVARIATE ANALYSIS
4.2.1 Relationship between Selected Socio-Demographic Characteristics, Breastfeeding Practices, Environmental Risk Factors, Health Care Service Utilization, Infanthood Diseases and Age at Infant Death
4.2.2 Relationship between Selected Socio-Demographic Characteristics and 59 Age at Infant Death
4.2.3 Relationship between Selected Socio-Demographic Characteristics, Breastfeeding Practices by Mothers
4.2.4 Relationship between Selected Socio-Demographic Characteristics and Infanthood Disease (Cough)
4.2.5 Relationship between Selected Socio-Demographic Characteristics and Infanthood Disease (Fever)
4.2.6 Relationship between Selected Socio-Demographic Characteristics and Infanthood Disease (Upper Respiratory Diseases)
4.2.7 Relationship between Selected Socio-Demographic Characteristics and Infanthood Disease (Diarrhea)
4.2.8 Relationship between Selected Socio-Demographic Characteristics and Environmental Risk Factor (Smoke Emission from Cooking Fuel)
4.2.9 Relationship between Selected Socio-Demographic Characteristics and Environmental Risk Factor (Source of Water)
4.2.10 Relationship between Selected Socio-Demographic Characteristics and Environmental Risk Factor (Toilet Facility)
4.2.11 Relationship between Selected Socio-Demographic Characteristics and Health Care Service Utilization in Government Hospital (Place of Antenatal Care)
4.2.12 Relationship between Selected Socio-Demographic Characteristics and Health Care Service Utilization in Private Hospital/Clinic (Place of Antenatal Care)
4.2.13 Relationship between Selected Socio-Demographic Characteristics and Health Care Service Utilization at Home (Place of Antenatal Care)
4.2.14 Relationship between Breastfeeding Practices and Infant Mortality 97 4.2.15 Relationship between Breastfeeding Practices by Mother and Age at Infant Death
4.2.16 Relationship between Mothers’ Breastfeeding Practices and Occurrence of Infanthood Diseases (Upper Respiratory Diseases)
4.2.17 Relationship between Mothers’ Breastfeeding Practices and Occurrence of Infanthood Disease (Cough)
4.2.18 Relationship between Mothers’ Breastfeeding Practices and Occurrence of Infanthood Diseases (Fever)
4.2.19 Relationship between Mothers’ Breastfeeding Practices and Occurrence of Infanthood Disease (Diarrhea)
4.2.20 Relationship between Environmental Risk Factors and Infanthood Diseases 108 4.2.21 Relationship between Environmental Risk Factors and Occurrence of Fever in Infants
4.2.22 Relationship between Environmental Risk Factors and Occurrence of Cough in Infants
4.2.23 Relationship between Environmental Risk factors and Occurrence of Upper Respiratory Disease
4.2.24 Relationship between Environmental Risk Factors and Occurrence of Diarrhea
4.2.25 Relationship between Environmental Risk Factors and Age at Infant Death
4.2.26 Relationship between Health Care Services Utilization and Age at Infant Death
4.2.27 Relationship between Health Care Services Utilization and Fever in Infants
4.2.28 Relationship between Health Care Services Utilization and Cough in Infants
4.2.29 Relationship between Health Care Services Utilization and Upper Respiratory Diseases in Infants
4.2.30 Relationship between Health Care Services Utilization and Diarrhea in Infants
4.2.31 Relationship between Health Care Services Utilization and Age at Infant Death
4.3 MULTIVARIATE ANALYSIS
4.3.1 Binary Logistic Regression of Occurrence of Infanthood Death and Treatment of Diarrhea among Children, Controlling for Independent and Intervening Variables
4.3.2 Cox Regression Analysis of Infant Mortality Showing the Interactions between Independent and Intervening Variable Effects on Infanthood Survival
4.4 Discussion

CHAPTER FIVE SUMMARY, CONCLUSION AND RECOMMENDATION
5.1 Summary
5.2 Conclusion
5.3 Recommendations
5.4 Limitation of the Study
5.5 Area for Further Research

REFERENCES

APPENDIX

DEDICATION

This work is dedicated to Pastor William Folorunso Kumuyi, the Founder and General Superintendent of Deeper Life Bible Church.

ACKNOWLEDGEMENTS

My sincere gratitude goes to my humble supervisor, Dr. B.L. Solanke for his tireless efforts to put me through every stage of this work. I am more than grateful to him for his constructive advice, precise suggestions and taking out of his tight scheduled to read through the draft of this work. It is a great privilege for me to have had him as my supervisor, for I have immensely benefited from his wealth of experience and countless knowledge. My sincere gratitude also goes to my co-supervisor, Dr. J. A. Kupoluyi for his timely and immense contribution towards the completion of this study. I cannot but appreciate him more.

It is important for me to mention particular individual who went extra mile to see to the completion of this project- I cannot but appreciate my honourable and immeasurable Head of Department, Professor P.O. Ogunjuyigbe. My in-depth gratitude goes to him for his advice and words of encouragement. My special appreciation goes to the Postgraduate coordinator, in person of Dr. L.A. Bisiriyu for his sincere and tireless efforts to see to the success of this study. I have a debt of gratitude to Dr. S. Bamiwuye, Dr. A. Akinyemi, Dr. A. Akinlo, Dr. A. Titilayo, Dr. O. Oyedokun, Dr. Adedokun, Mrs. M. Obiyan, Mrs. Banjo, Mr. A. Olufemi, Mrs. Ishola Mrs. Fasokun and other teaching and non-teaching staff in the department for their suggestions, encouragements and moral supports. I have a debt of gratitude to Dr. Oluwagbenga Orimoogunje, Dr. Ilesanmi Oluwatoyin and Professor Olabisi Aina. I cannot but show my whole gratitude to you all for motherly and fatherly role played as the case may be.

I cannot but show my unfathomable gratitude to the following persons: Ms. Dafa Ameenat and Malam Buba Baba Garba in Yobe State; Mr. Patrick Paul, in Kaduna State; Malam Ado Umar and Ms. Bulus Aminya in Gombe State, as well as Mr. Pwol Gyang and Madam Monica in Plateau State. Please accept my whole appreciation on your immense contribution during the conduction of the qualitative aspect of this work.

My sincere appreciation goes to my supportive colleagues and friends in persons of Mr. Olaniyan Kayode, Mr. Olaoye-Oyesola Dare, Mr. Ibinaye Taiwo, Mr. Ufot Joseph, Mr. Adeniran Bolaji, Ms. Husseina Mr. Chukwuma Rock, Mr. Akinola Kehinde, Mr. Daramola Dare Samuel, Mr. Olanipekun Samuel, Mr. Akinola Samuel, Mr. Toriola Olawale, Ms. Olaleye Ronke, Ms. Ogbunofor Favour, Mr. Soliu Ogunmola, Ms. Oguche Maria, and Mr. Agbaka Paschal. I am very grateful to you all. My sincere gratitude also goes to Ms. Tolson Shantell, Ms. Tolson Sherrie, Ms. Gilliam Victoria, Ms. Omotunde Adedoyin, Ms. Otung Radiance, Mrs. Jenkins Christine, Ms. Amos Grace, Ms. Lawal G. Elizabeth and Master Kayden. I thank you all for your contribution towards the success of this study.

I am highly indebted to my glorious and spiritual fathers in the Lord in persons of Pastor W.F.Kumuyi, Pastor J. Salau, Pastor Samuel Itakpe, Pastor Albert Abegunde, Pastor Omogoriola, Evangelist Taiwo Ayangbile, Brother Deji, Brother Mayowa, Brother Olatunji Oluwaseyi and the entire brethren of Deeper Life Postgraduate Christian Fellowship, Obafemi Awolowo University Chapter. I cannot but appreciate you all. I owe an in-depth gratitude to my parents Mr. and Mrs. Bankole Adeyemi and my siblings for believing in me, their prayer and supports both financially and materially. I cannot but appreciate you all. My contless appreciation also goes to my very dear and priceless pearl, Ms. Majoro Majoale Alinah. I owe her a lot of gratitude for her encouragement and immeasurable supports the successful completion of this work.

Finally, I am so grateful to the Almighty God for His Direction, provisions, mercies, grace as well as mental and physical strength He has bestowed upon me at every stage of this work.

Bankole, O.T.

2014.

ABSTRACT

This study assessed the pattern of breastfeeding practices among mothers; determined the relationship between women’s socio-demographic characteristics and their breastfeeding practices; examined the relationship between women’s socio-demographic characteristics and infant mortality and ascertained the relationship between breastfeeding practices and infant mortality. This was with the view to encouraging exclusive breastfeeding practice among mothers as a measure not only for promoting infant nutrition but also as a strategy through which infant mortality can be reduced to the lowest possible rate in Nigeria.

The study employed both primary and secondary data. Secondary data for the study was obtained from the Nigeria Demographic Health Surveys (NDHS 2008).The Survey elicited information from 33,385 women of reproductive aged 15-49, as well as information from 28,647 children whose ages were below five years. 2008 NDHS Data on women of reproductive aged 15-49 in the North of Nigeria who have had at least a child in the past five years preceding the survey was extracted for 12,210. The 2008 NDHS Data on children of age below five years old in the North of Nigeria was extracted for 19,552. Forty in-depth interviews (IDIs) were conducted in four randomly selected states. Plateau and Kaduna states were selected from North Central and North West respectively. North East 109 infant deaths per 1000 live births was the highest across the regions in Nigeria, hence, Gombe and Yobe states were selected in North East representing the three Geo-Political Zones of Nigeria respectively. Ten IDIs was carried out in each of these states. Five IDIs were conducted randomly in rural and urban areas of each of these four states respectively. An interview guide was developed to elicit information from women of reproductive aged 15-49 who have had at least a child in the past five years on the following variables: socio-demographic characteristics of mothers, breastfeeding practices, child’s immunization, source of drinking water, how often child falls sick, how they treat infanthood diseases and infant deaths. Responses to these complement the results from the secondary source. Content analysis was employed to analyse responses from IDIs. The secondary data was analysed using frequency distribution, chi-square test, binary logistic and cox regression statistics.

Results showed that pattern of breastfeeding among mothers was significantly associated with age (χ2=83, p<0.05), level of education (χ2=66, p<0.05), wealth status (χ2=56, p<0.05), employment status (χ2=67, p<0.05), type of occupation (χ2=94, p<0.05), ethnicity (χ2=114, p<0.05), partner’s level of education (χ2=48, p<0.05) and place of residence (χ2=15, p<0.05) respectively. The results showed that mother’s socio-demographic characteristics and infant mortality was significant. Mother’s socio-demographic characteristics was significantly associated with age (χ2=46, p<0.05), wealth index (χ2=17, p<0.05), occupation (χ2=39, p<0.05), births in the last five years (χ2=39, and mother’s level of education (hazard ratio=0.9612, p<0.05). The cox regression survival analysis results showed that infant mortality was significant with exclusive breastfeeding (hazard ratio=0.0829, p<0.05) and duration of breastfeeding (hazard ratio=0.8178, p<0.05).

The study concluded that exclusive breastfeeding is crucial for reducing infant mortality.

CHAPTER ONE 1.0 INTRODUCTION

1.1 Background to the Study

Infant mortality is defined as the death of a child less than a year of age (Andrew, Brouillette and Brouillette, 2008; World Health Organization [WHO], 2000). Also, it is defined as the death of baby before he or she attains age one (National Centre for Health Statistics, 2011). Infant mortality rate, a measure of child’s survival is one of the indicators (other indicators include per capita income, level of infrastructural facilities, current account and finance) used in the measurement of economic development globally. Infant mortality rate is a stronger indicator compared to other indicators. Findings from several studies have shown that the survival of newly born children depends largely on the socio-economic status of their parents, care available to them as well as the condition social environment, such as their physical surroundings, cultural settings and social relationship (Twum-Baah, 1994; Manda, 1999; Madise, 2003; Mutunga, 2004; Kwabena, 2011; Kamal, 2012).

Infant mortality reflects both the actual state of the general medical and public health conditions in different countries of the world (WHO, 2007). According to a report on environmental hazard by WHO in 2007, the high prevalence rate of infant mortality in virtually all the developing countries of the world has led to negative effects on the pace of socio-economic development. The majority of approximately 4 million new born babies that die annually occur in the developing countries of the world (United Nations Children’s Fund [UNICEF], 2012). Recent study shows that substantial progress has been made towards achieving the “Millennium Development Goal 4”; about 14,000 fewer children died every day in 2011 than in 1990 (UNICEF, 2012).

More so, recent reports have shown that while infant mortality rates in other developing countries of the world are falling steadily: 3 infant deaths, 5 infant deaths, 8 infant deaths and 11 infant deaths per 1000 live births in Cuba, Malaysia, Chile and Thailand respectively, the same cannot be said on the African continent. The worse affected are the countries in the sub-Saharan Africa. In Egypt, Tunisia and Libya; the infant mortality rates are 19 deaths, 14 deaths and 13 deaths per 1000 live births compared to 106 infant deaths, 112 infant deaths and 114 infant deaths per 1000 live birth in Central Africa Republic, Congo Democratic Republic and Sierra Leone respectively (Population Reference Bureau[PRB], 2012). According to the report by UNICEF, 2012, the high infant mortality rate of 78 infant deaths per 1000 live births in Nigeria is influenced and aggravated by the poor disease treatment mainly as a result of inadequacy of health care delivery services in the country (National Population Commission [NPopC] and ICF Macro, 2009).

The attainment and sustenance of socio-economic development of countries of the world are directly associated with the level and state of infant survival, maternal health status as well as the general wellbeing of the population at large (PRB, 2012). In most of the developing countries, infant mortality rates are still at least 10 times higher than in developed countries of the world (PRB, 2012). For example, two thirds of infant deaths that occurred in the rural plains of Nepal, Bangladesh and North India were recorded in the environment with minimal antenatal or trained obstetric care (Jones and Steketee, 2003). Besides, education makes a woman to utilize prenatal care and easily comply to immunize their children against deadly and chronic infections (Hobcraft, 1993). Similarly, a research finding carried out by Bhutta and Yusuf (1997) in Pakistan shows a 3-fold reduction in the risk of neonatal sepsis breastfed children compared with the partially breastfed hospitalized neonates. Furthermore, Mazhar (2013), in his study affirms breast milk nutrients as the appropriate replacement for the unbalanced diets and micro-nutrients deficiencies are the major factors responsible for the increased risk of chronic diseases and stunted growth among infants in Nigeria.

Research study shows that 43% of worldwide under-five mortality currently occurs in Africa (WHO, 2005). More so, in a related research study carried out by Arifeen, Black, Baqui, Caulfield and Becker (2001), it was discovered that infant and under-five mortality are high as a result of high prevalence of infant and childhood diseases. The findings from this study shows that artificially-fed infants are at the risk of having the following diseases: allergies, asthma and respiratory diseases, gastro-intestinal disease, overweight and obesity, diabetes, dental caries, deficient response to childhood immunizations, hypertension and high cholesterol level and sudden infant-death syndrome (Arifeen, Black, Baqui, Caulfield and Becker, 2001).

Similarly, infants who are fed with supplements tend to have poor brain development than infants that are breastfed as well as lower cognitive development from age of 6 month through 16 years of age and lower Intelligent Quotients than infants that are fed with breast milk exclusively (Lauer, 2005). More so, Infants aged 0-5 months who are not breastfed have seven fold and fivefold increase of deaths from diarrhea and pneumonia, respectively, compared with infants of this age range that are exclusively breastfed (Victora, Smith and Vaughan, 1989). More so, NPC and ICF Macro, (2009) shows that infant mortality which would have been reduced if exclusive breastfeeding had been practiced among mothers increased from 97 infant deaths between 1993 and 1998 to 99 infant deaths between 1998 and 2003, while it declined to 78 infant deaths per 1000 live births (UNICEF, 2012). Nigeria is currently 16th among the 20 countries with the highest level of infant mortality in the world (PRB, 2012).

The infant morbidity and mortality rates in Nigeria and in neighbouring countries of West Africa have been on the rise despite the effort of mothers to breastfeed their infants and young children (Anyanwu and Enweonu, 2004). However, on the average, mothers in Nigeria still do not have the full understanding of exclusive breastfeeding. Subsequently, an average infant in Nigeria is vulnerable to death at infant as a result of inadequate nourishment (Okolie, 2012). Studies have shown that mother’s full knowledge on exclusive breastfeeding goes a long way in the successful practice of exclusive breastfeeding practice (Agampodi, 2007; Okolie, 2012). Similarly, infants and young children in most developing countries of the world are vulnerable to malnutrition as a result of the poor knowledge of their mothers on how to feed them exclusively with breast milk thereby preventing them from being infected with infanthood and childhood diseases (Bernadette, 2003; UNICEF, 2003). It was recently reported that about 8 million children died before reaching the age of five as a result of pneumonia, diarrhea and birth complication as a result of poor nutrition and non-adherence of mothers to exclusive breastfeeding of their infants in 2010 (UNICEF, 2012). According to Maduforo (2013), many mothers that are still breastfeeding their young ones are not practicing exclusive breastfeeding due to their inadequate knowledge of breastfeeding. Consequently, large proportions of children are suffering from one form of malnutrition diseases and another ranging from stunted growth to micronutrient deficiencies (Ajibade, Okunlade, Makinde, Amoo, Adeyemo, 2013). In a recent study by UNICEF, (2012) it has been observed that as many as 1.45 million “lives” are lost as a result of non-adherence to exclusive breastfeeding in developing countries. It is against this background that this study focuses on the socio-demographic factors, breastfeeding practices and infant survival.

1.2 Statement of the Research Problem

Studies have shown that the duration and practice of exclusive breastfeeding among women who had child-delivery in a health facility, and outside such health facility in Nigeria, have remained relatively low (Otoo, 2009; Ogunlesi, 2010; PRB, 2012). In Nigeria, socio-cultural, economic and political factors have been identified in recent studies as the major factors hindering the adoption of exclusive breastfeeding among lactating mothers (Okolie, 2010; Ekanem, 2012; Maduforo, 2013). Masarenhas (2006) observes that the adherence to exclusive breastfeeding practices by women can be interrupted by women with low family income, type of education as well as the age of mothers.

A recent study findings have shown that the adoption of exclusive breastfeeding practices by mothers are being hampered as a result of rapid urbanization and a shift by women from their previous roles of home-keeping to paid-economic activities (Ademola, 2011). Thus, the proximity of mothers to their babies, particularly for the working-class mothers has been identified as one the bottlenecks preventing women from practicing exclusive breastfeeding in most urban centres (Lilian, 2006). On the other hand, the exposure of women to mass media has been identified as an important mechanism through which women’s are enlightened on the full knowledge of exclusive breastfeeding (Rajesn, 2009; Ajibade, 2013; Dessalegn, 2013). According to Kwabena (2013), maternal knowledge is directly related with paternal educational level, attending antenatal care, having access to radio, using family planning and delivered of babies by health workers. Similarly, studies have shown that there exists a relationship between the level of education of mothers and their full knowledge of exclusive breastfeeding practices (Nobel, 2003; Salami, 2006; Awogbenja, 2010; Okolie, 2012; Maduforo, 2013).

Few studies have identified breastfeeding as a major mechanism through which infants’ health can be improved and their survival enhanced. Most of these studies have their focus on fertility control, thus breastfeeding is seen as a mechanism of child spacing which in the long has the effect of controlling fertility and reducing the number of parity that a women may have through her reproductive years (Bhutta, 1997; Nath and Singh, 2000; WHO, 2000; WHO, 2000; Arifeen, 2001; Chantry, 2006; Odu and Ogunlade, 2011 PRB, 2012; UNICEF, 2012). However, in spite of the existing numerous studies on breastfeeding practices in the country, few studies have specifically explored socio-demographic factors and breastfeeding practices as correlates of infant morbidity and mortality in the country. Rather, previous studies have established breastfeeding practices as a mechanism of child spacing. Other studies have focused on the subject matter as a means of preventing bleeding, breast and ovarian cancers among mothers. This study therefore explored the socio-demographic factors and breastfeeding practices as correlates of infant morbidity and mortality in Northern Nigeria.

1.3 Research Questions

This study is designed to provide answers to the following questions:

(i.) What is the pattern of breastfeeding practices among mothers in Northern Nigeria?
(ii.) Is there any relationship between the socio-demographic characteristics of mothers and their breastfeeding practices?
(iii.) Is there any relationship between the socio-demographic characteristics of mothers and infant mortality?
(iv.) Is there any relationship between breastfeeding practices and infant mortality?

1.4 Objectives of the Study

The general objective of the study is to investigate the relationship among socio-demographic factors, breastfeeding practices of women and infant health and mortality in Northern Nigeria. This was with the view to encourage exclusive breastfeeding practice among mothers as a measure not only for promoting infant nutrition but also as a strategy through which infant mortality can be reduced to the lowest possible rate in Nigeria.

The specific objectives of the study are to:

(i.) assess the pattern of breastfeeding practices among mothers in Northern Nigeria.
(ii.) determine the relationship between mother’s socio-demographic characteristics and their breastfeeding practices.
(iii.) examine the relationship between mothers’ socio-demographic characteristics and infant mortality.
(iv.) ascertain the relationship between breastfeeding practices and infant mortality .

1.5 Justification for Study

The National Policy on Infant and Young Child Feeding in Nigeria was revised in 2004 with the overall goal of ensuring the optimal growth, protection and development of Nigeria Child from birth to the first five years of life (Federal Ministry of Health [FMOH], 2005). Recent research studies carried out by UNICEF in 2012 have affirmed that more than 3 million babies die every year in the first month of life. More so, the probability of a baby born in sub-Saharan Africa dying before reaching age five of a prevented death is about 16.5 times higher than that of a child born in the developed countries of the world (UNICEF, 2012). According to a report by WHO in 2001, the period of birth to 2 years of age is recognized as a critical period for which adequate nutrition must be provided for the child in order to promote the development and enhancement of health and behaviour of the child. As affirmed in the Innocenti Declaration (1990), the WHO/UNICEF has called for formulation and implementation of policies that would promote and support cultural practices with the aim of encouraging exclusive breastfeeding of new born babies up to their second year and beyond after birth.

Nigeria’s infant mortality rate of 78 infant deaths per 1000 live births which makes the country the sixteen largest in the world explains the country’s relatively adherence to exclusive breastfeeding by women (UNICEF, 2012). According to 2008 NDHS reports, there has been a substantive rise in the breastfeeding practices among mothers in Nigeria: by comparison, only 21% of infants below 2 months of age were exclusively breastfed in 1990 and 3.1% were not breastfed at all; more so, 20.1% were exclusively breastfed in their month of births, and 2.6% of these infants were not breastfed at all in their first month of life. However, there are differentials in the practice of exclusive breastfeeding across the six geo-political zones of the country. The median duration (months) of breastfeeding among children born in the past three years are put at 0.4 for North East and North West respectively; 0.5 for North/Central, South/East and South/South respectively; while that for South West is put at 0.6 (2008 NDHS dataset). On the other hand, the Nigeria 2008 NDHS data set and UNICEF data on infant mortality Nigeria show that Nigeria still remains one of the highest contributors to global infant mortality with 78 infant deaths per 1000 live births, although with the total number of infant deaths in the country put at 519,000 and 480,000 infant deaths in the year 1990 and 2001 respectively (UNICEF, 2012). However, reports from the survey show that there are differentials in the infant mortality rates [IMRs] across the six geo-political regions of Nigeria. The IMRs are put at 59 deaths, 77 deaths, 84 deaths, 91 deaths, 95 deaths and 109 deaths per 1000 live births in South/West, North/Central, South/South, North/West, South/East and North/East respectively (2008 NDHS).

Therefore, considering the average infant mortality rate of 92 deaths per 1000 live births in Northern Nigeria compared with 79 deaths per 1000 live birth in the Southern Nigeria, the choice of conducting the study in Northern Nigeria has been justified. Obviously, there is further doubt that successful breastfeeding can be adopted to correct infant malnutrition, promote healthy living and enhance survival of both mother and her baby. This study focuses on breastfeeding practices and infant health, which are crucial to all efforts seeking to promote infant survival and attaining MDG 4 in the country. Hence, exploring socio-demographic factors and breastfeeding practices as correlates of infant morbidity and mortality will serve as a vital mechanism through which the attainment of 35 infant deaths per 1000 live births can be achieved in Nigeria if not by 2015, but in the nearest future.

CHAPTER TWO

2.0 LITERATURE REVIEW

This chapter discusses the existing literature review on socio-demographic factors, breastfeeding practices and infant mortality. The chapter explored the interaction between socio-demographic factors and breastfeeding practices among mothers, and the effects of their interaction on infant mortality. Also, this chapter discusses the theoretical framework for the study and states the hypotheses of the study.

2.1 Meaning and Categorisation of Breastfeeding

The term “Breastfeeding” is defined based on its categorization and the individual defining it. Breastfeeding is defined as the normal way of providing infants with nutrients for healthy growth and development (WHO/UNICEF, 1991). Breastfeeding is the act or means of feeding the child with breast milk directly from the mother’s breast or wet nurse or expressed with breast milk, solid or semi-solid foods and also requires the feeding of infant with non-human milk (UNICEF, 2012). The following are the various categorization of breastfeeding: Exclusive Breastfeeding; Partial Breastfeeding; and Complementary Breastfeeding

The term “Exclusive breastfeeding” also referred to as continuous breastfeeding means that the infant is fed with breast milk expressed in addition to the breastfeeding from the mother or wet nurse, and might be supplemented with drops, syrups (vitamins, minerals, medicine), but with the exception of any other liquid or semi foods. Infants are recommended to be exclusively breastfed for the first six months of life by their mothers or wet nurses (WHO/UNICEF, 1991). On the other hand, “Partial Breastfeeding” unlike exclusive breastfeeding means the feeding of infants predominantly with breast milk, which is expressed milk from the mother or from the wet nurse. Partial breastfeeding makes allowance for feeding of infants with liquids which vary from water, oral hydration solution, water based drinks, fruit, juice to drops of vitamins, minerals and medicines. Partial breastfeeding is also referred to as predominant breastfeeding. It does not allow the feeding of infants with any other forms of expressed breast milk other the ones mentioned above. Both exclusive breastfeeding and partial breastfeeding make up Full Breastfeeding (WHO/UNICEF, 1991). However, the term “complementary breastfeeding” allows the feeding of infants with expressed breast milk as well as with solid or semi-solid foods. It permits the infant to receive any food or liquid including non-human milk. Complementary breastfeeding allows the feeding of the infants with other foods aside breast milk after six months of age (UNICEF, 2012).

2.2. Factors Influencing Breastfeeding Practices among Mothers

Breastfeeding is a two-food mechanism through which maternal and child health can be enhanced. It nourishes the infant, protects him or her against infanthood and childhood deadly diseases and keeps the infant safe for healthy adulthood living (Umar and Oche, 2013). Breastfeeding, if prolonged prevents unwanted pregnancy, thus serving as a maternal health intervention (Nath, 1994; Hector, 2004; Fatoumata, 2009; Shams, 2013).A study finding has shown that not more than 35% of infants are exclusively breastfed during their first four month of life worldwide (Du Plessis, 2009). In 2007, World Health Organization recommended exclusive breastfeeding as one of its primary aims of nutrition and public health programmes worldwide. The breastfeeding practices adopted by mothers are influenced by intention, support, confidence and self-efficacy (Meedya, Kathleen and Ashley, 2010). On the otherhand, according to Gibbons, (2000), intention is a formulated plan aimed towards the attainment of a specific goal with the aid of certain instrumental actions.

Therefore, the intentions of how long a woman would breastfeed her baby depends to a large extent on her inner’s desire to breastfeed (Meedya et al., 2010). Blyth and Creedy (2004), in a longitudinal study of 300 Australian women discovered that mothers who intended to breastfeed for a period of 12 months were likely to continue breastfeeding until four months compared to mothers whose intentions were to breastfeed for less than 6 months. Also, Breastfeeding desire of a mother could be as a result of breastfeeding intention and the influence of people in her social network (DI Girolamo, 2005; Ogunba, 2013; Maduforo, 2013). Thus, the attitude and behaviour of mothers are sometimes influenced by their husbands, close relatives and health care providers in their social networks (Scott, Shaker and Reid, 2004; Swanson and Power, 2005; Ajibade, 2013).Similarly, the attitude of nursing mother’s husband to breastfeeding is essential to women’s attitude and her breastfeeding behaviour (Mc Grath, 2000; Scott, Shaker and Reid, 2004; Okolie, 2012; Maduforo, 2013).

In line with this, recent study findings on breastfeeding practices among nursing mothers show that in communities of high ambient breastfeeding levels, the major changes that might be achieved are increases in early initiation and exclusive breastfeeding practices (WHO, 2013). However, Blyth and Creedy (2004) in their studies discovers that early cessation of breastfeeding leads to low maternal breastfeeding confidence. Dykes and Williams (1999) findings show that the deterioration in breastfeeding confidence during postnatal period is an important factor in the decision to cease breastfeeding. Grummer Strawn (1996), in his research study on the influence of socio-demographic and economic factors on the breastfeeding affirms that the mother’s childhood residence, educational attainment of parents, age of mothers, mother’s occupation, parity, contraceptive use as well as the presence of other siblings in the home have substantive influence on the breastfeeding practices of mothers. Relatively, the educational attainment of mothers goes a long way to influencing their breastfeeding practices than age of mothers (Duboia and Girard, 2003; Rajesn, 2009).

Education has the most significant influence on breastfeeding duration, and higher educational attainment has been found to be positively related with initiation and duration of breastfeeding by mothers in most developed nations of the world (Hoddinott and Tappin, 2008). More so, Hector (2004) according to the findings that educational interventions that encourage both prenatal and postnatal periods would serve as the most effective interventions needed to promote and support breastfeeding among mothers. There are great possibilities in the interaction between higher education and socio-economic status, which increases the mother’s capability to purchase infant formula rather than practice full breastfeeding (Hoddinott, Craige and Mclnnes 2012). Studies have shown than the duration of breastfeeding by mothers is greatly influenced by the length of maternity leave as well as the expected time of resumption to work by working mothers (Dennis, 2002). However, a longer time period of up to six months of exclusive breastfeeding can be influenced by supplementing education programmes with support from a health professional and peer counsellor (Dennis, 2002; Awogbenja, 2010; Ogunba, 2013).

Relatively, the frequency of breastfeeding is very high among breastfeeding mothers in South West Nigeria (Odu and Ogunlade, 2011). However, breastfeeding practices among mothers in Nigeria are being influenced through antenatal group discussion, the presence of peer support, particularly amongst mothers from low income groups, and maternity routines which support mother infant contact (Fairbank, 2000; Ekanem, 2012; Maduforo, 2013). Dyson (2006) posits that effective interventions in promoting of breastfeeding initiation and duration have influence on the constant breastfeeding behaviour among mothers. Thus, the intention to adhere to one form of breastfeeding practice or another has a link to the socio-cultural and economic status of women across the world (Swanson and Power, 2005)

2.3 Prevalence of Breastfeeding Practices among Mothers in Nigeria

The practice of breastfeeding has remained the major aspect of infant feeding in Nigeria and many of the countries in the sub-Saharan Africa (Awogbenja, 2010). Studies have shown that exclusive breastfeeding rate in Nigeria declined from 17% in 2003 to 13% in 2008 (National Population Commission [NPopc] and ICF Macro, 2009). Similarly, the NDHS (2008) reports reveal that while 34% of infant 0-5 months of age were given water in addition to breast milk, 10% were given non-milk liquids and juice, and 6% were fed with milk other than breast milk. The reports of the survey further show that 325 of children 24 months of age were still being breastfed. The median breastfeeding duration in Nigeria has been put at 18.1 months, while the median age for exclusive breastfeeding is just for duration of 15 days. More so, fragments of just 13% of infants are exclusively breastfed throughout the first 6 months of life. Similarly, the report has shown that 16 % of infants whose ages are less than 6 months are fed with a bottle with a nipple, while the proportion that are bottle-fed is put at 17% among infants in the age group 2 to 3 months and 4 to 5 months respectively (National Population Commission and ICF Macro, 2009).

The adherence of Nigerian mothers to exclusive breastfeeding practice is significantly influenced by their knowledge of the importance of breastfeeding as well as its consequences (Ogunba, 2006; Awogbenja, 2010; Ajibade, 2013; Umar, 2013). The exclusive breastfeeding rate among mothers in North Central Nigeria has been discovered to be as low as 20% (Awogbenja, 2010). In Plateau State for example, the rate of exclusive breastfeeding is put at 6% (Amosu, 2010). On the otherhand, non-exclusive breastfeeding have been attributed to possible poor knowledge of mothers on the positive health implications that exclusive breastfeeding can have on them and that of their babies; it was discovered that only 35.8% of mothers were aware of these health benefits (Awogbenja, 2010). In line with this, the low practice of exclusive breastfeeding practice among mothers have been linked to the cultural and religious beliefs that babies should be fed with various forms of oral syrups with the strong conviction these are social rites that must not be contravened as these beliefs of theirs are believed to protect the babies against both spiritual and physical illness that might befall the baby if not observed (Muchinna , 2010; Ukegbu, 2011; Umar and Oche, 2013).

However, the awareness on exclusive breastfeeding in the country is gradually on the increase with the timely intervention by the government of Nigeria, where by every possible effort is being put in to see to encouragement and adherence to it by the nursing mothers (Awogbenja, 2010). According to the NDHS (2003), there is a positive relationship between place of delivery and breastfeeding initiation. The Survey reports reveals that 40% of women who delivered at health care facility, where there were professionals, initiation of breastfeeding within an hour compared to less than 30% in mothers who delivered elsewhere (NDHS, 2003). Salami, (2006) identifies level of educational attainment, occupation of parents, and place of delivery as the major determinants influencing breastfeeding practices among mothers in North Central Nigeria. Similarly, the poor knowledge of breastfeeding practices and importance, plain water as pre-lateral food, delayed initiation as well as family and peer influences have been discovered as some of the major contributory factors to low breastfeeding practices among most nursing mothers in the country (Awogbenja, 2010; Ukegbu, 2011; Ekanem, 2012).

2.4 Early Breastfeeding Practices among Mothers

There has been considerable argument about the ideal timing of a first breastfeed, and it is agreeable that the initiation of breastfeeding among mothers should begin immediately after the birth of the baby (WHO, 1998). However, there is no evidence of a “critical period” or timing of the first feeding that is agreeable as the most appropriate (Britton, 2007). Rather, it is suggested that breastfeeding within an hour or thereabout after delivery of the baby seems optimal (Colson, 2007). Early and close contact between the mother and her baby is considered essential with breastfeeding taking place when the mother and her baby are ready (Moore, 2007). However, accessibility of mothers to professionals’ health care support after delivery will enhance their baby’s first breastfeeding (Renfrew, 2000; Odu and Ogunlade, 2011). Besides, Mulder (2006) explains that early breastfeeding should be pain-free for mothers and effective for her baby. The healthcare supports provided by healthcare professionals need to be directed to assisting the mother to achieve a comfortable position for breastfeeding, pain relief if necessary and use of a comforting rather controlling approach (RCM , 2002). It has been found appropriate to observe privacy and to encourage the first breastfeeding to take place while the mother’s preferred support is still within her (Enkin , 2000; Ogunba, 2013).

Moore (2007) findings reveal that skin-to-skin contact for mothers and their babies has an influence on first breastfeed from mothers to their babies. Findings from studies have affirmed that skin-to-skin breastfeeding does not only have significant positive effects on initiation of breastfeeding but also has some positive maternal and neonatal physiological and behavioural outcomes (Dermott, 2006; Moore, 2007). More so, mothers should not be separated from their babies unless there is a life threatening occurrence (Dermott, 2006). Olsen (2000) suggests that institutional should not be allowed to interfere with the responsibility for mothers and their babies to be together. Meanwhile, the intramuscular administration of vitamin K has been suggested, and opposing practice is recommended to ensuring maternal comfort measures and breastfeeding (Shah, 2006). However, the administration of oral vitamin K preparations to babies should be done in such a way that will not encourage negative associations with breastfeeding (Renfrew, 2000).

2.5.0 The Influence of Socio-Demographic and Economic Factors on Infant Mortality

In order to achieve the Millennium Development Goal 4 which seeks a two-thirds reduction of infant and child mortality by 2015, there is a need to identify and rank-order the benefits of socio-economic determinants that influence infant survival (Hisham and Clifford, 2008). The survival of infants unlike any other age group of a population is immensely influenced by the socio-economic conditions of their immediate environment (Madise, 2003; Darmstadt, 2005; Ademola, 2011; Desta, 2011). Infant mortality and morbidity are majorly caused by injuries (Guyer and Elers, 1990). In most developed countries, socio-economic factors are not the major causes of infant deaths However, the reverse is the case in most developing countries; the development in science and technology has not fully been integrated in developing countries; infant mortality rates are still at least 10 times higher in developing countries than in developed countries of the world (PRB, 2012). Recent findings have shown that most infant deaths occur in the prenatal and neonatal periods; these deaths have been linked to premature, intrauterine growth retardation, and congenital infection (WHO, 2012).

2.5.1 Educational Attainment, Economic Status and Infant Mortality

Caldwell (1979) theory of wealth flow explains that mother’s education works through changing feeding and care practices, creating a better health seeking behaviour for mothers, and thereby changing the traditional family relationship. Thus, child’s and infant’s survival can be enhanced by education (Caldwell, 1979). Education prolongs the age of marriage and woman’s age at first birth thereby making such woman a bearer of fewer children (Hobcraft, 1993). Besides, education makes a woman to utilize prenatal care and easily comply to immunize their children against deadly and chronic infections (Hobcraft, 1993). Relatively, Kramer (2001) and Okolie (2012) explain that a higher degree of education of mothers promotes better knowledge of health practices, for a proper understanding of advices given by health workers and make parents aware of the importance of medical follow up. However, a study has shown that infant mortality is higher in those infants born to mothers with high school compared to women without (Adetunji, 1995). Low maternal age at birth as well as less education of breastfeeding associated mothers with high school education might be the cause for this finding (Adetunji, 1995).

Haas (2005) findings reveal that mothers who do not have enough for food or shelter are at higher risk of depressive symptoms or physical functioning and might consequently have negative effects on their behavioural as well as their maternal characteristics. On the other hand, mothers with sufficient financial strength and with a higher level of education are more likely to attain optimal health services and to receive better health care in the event of unexpected or expected complication at delivery (Haas, 2005; Mascarenhas, 2006). According to Hill (2001), there is an inverse relationship between mother’s education level and economic status and child survival. Thus, maternal education remains an important determinant of mother’s age at marriage; mothers with higher education levels delay their first births and often end up with less number of parities (Beets, 2004).

2.5.2 Birth order, Mother’s age at first birth and Infant Mortality

The risk of infant and child mortality is higher for first order and very young and steadily begins to decline in the subsequent birth orders (Desta, 2011). Among socioeconomic variables birth interval with preceding birth and mothers education have been identified to have significant effects with reduced risk of infant and child mortality as compared to children born to mothers with primary education level or non-educated (Twum-Baah, 1994; Ekanem, 2012; Maduforo, 2013). However, according to the study findings by Kombo and Ginneken 2009, the influence of birth order, preceding birth interval, maternal age, type of birth and sanitation factors are more pronounced on infant mortality but with weak effect on child mortality. Manda (1999) posits that the breastfeeding status of mothers does not alter the influence of preceding birth interval period on infant and child mortality risk among nursing mothers in Malawi. On the otherhand, Muntago (2004) study findings reveal that infant and child mortality were lower for children who were at birth order 2-3, birth interval more than 2 years, single births, living in wealthier households, and mothers who had access to safe drinking water and less polluted environment compared to those who were denied all these.

2.5.3 Place of Residence and Infant Mortality

Studies on infant and child mortality, particularly in most sub-Saharan African Countries have shown that the prevalence is higher in rural settlements than in the urban areas (Akoto and Tabutin, 1990). Also, the risk of death during childhood as a result of younger age of mothers has been affirmed to be higher in rural areas than in the urban settlements (Akoto and Basile, 2002) In line with this, the risk of infant death among urban children in Tanzania was found to be half higher than among rural children as a result of either deteriorating living conditions in urban areas as compared to the rural settings, or the rapid improvement in socio economic conditions in the rural settlements as compared to the urban areas (Akoto and Basile, 2002). Similarly, the differences in the prevalence of infant and child mortality in rural and urban areas have been linked to the homogeneity of the rural areas and the heterogeneity of the urban settlements (Akoto, 1990; Ademola, 2011).

Magali and Vallin (1996) in their studies on effects of crisis in sub-Saharan Africa argue that the short term effects of crisis are highly significant with a great possibility of immense negative imparts in the long run. According to their findings, people’s health will be undermined, so that they will not be as prepared to withstand challenges from natural disasters, political unrest, wars and effects of AIDS on the economy. On the otherhand, urban-rural differences in quality of education, state of public and community health infrastructures have been identified as some of the major factors that might be responsible for lower infant mortality in urban areas compared to some noticed higher infant death prevalence in some few rural areas (Sahn and Strife, 2003; UNICEF, 2012).

2.6.0 Breastfeeding practices of Mothers and Infant Mortality

Breastfeeding is exceptionally important among mothers because its practice is fundamental for survival, growth, development, health and nutrition of infants (WHO, 1998). Breastfeeding enables frequent interaction between mother and her baby, thereby fostering emotional bonds, a sense of protection, and stimulus to the baby’s developing brain (WHO, 2003). The early initiation of breastfeeding , exclusive breastfeeding and birth spacing can serve as basic interventions if completely adhered to by mothers; they have brought about reduction in infant deaths from 13 million globally in the 1990’s to 8.8 million in 2008 (Zaney, 2011).

2.6.1 The influence of Early and Exclusive Breastfeeding on Infants’ Health and Mortality

Darmstadt, Bhutta, and Cousens (2005) observe in their studies that early initiation of breastfeeding lowers the rates of prenatal and infant mortality. Similarly, WHO (2000) report on infant feeding shows a higher protective effect against mortality of any breastfeeding in the first two months compared with later ages. More so, early initiation of breastfeeding (days 1-3) lowers diarrhea during infancy, and among all preventive health and nutrition, improved breastfeeding has been discovered as such with the greatest potential to reduce both infant and under five child mortality up to 13% (Jones and Steketee, 2003). Exclusive breastfed infants have been found to be less vulnerable to the risk of diarrhea as well as other respiratory infections in infants compared with those that were not exclusively breastfed (Chantry, Howard and Auinger, 2003). Similarly, Fatoumata et al, (2009) adds that the risk of morbidity is reduced by 70% when a child is exclusively breastfed. Exclusive breastfeeding protects the baby against exposure to unsafe food or waste and thereby promoting the survival of the infant (Zaney, 2011). Breastfeeding of infants immediately after child’s birth is said to prevent mothers from bleeding and also protects them against the risk of developing breast and ovarian cancers while optimal breastfeeding practices among mothers have been identified and recommended as the bedrock of a healthy life for infant health and child survival (Zaney, 2011).

Recently, Mazhar (2013) affirms breast milk nutrients as the appropriate replacement for the unbalanced diets and micro-nutrients deficiencies are the major factors responsible for the increased risk of chronic diseases and stunted growth among infants in Nigeria. Relatively, abnormal feeding among nursing mothers has been identified as the major factor that causes poor growth and development, reduced immunity, risk of infections and diarrhea disease, infant constipation, alteration in glut flora among infants in Nigeria (Ademola , 2011). Also, Bhutta and Ysuf (1997) reported a 3-fold reduction in the risk of neonatal sepsis in exclusively breastfed compared with the partially breastfed hospitalized neonates. Similarly, Victora CG, (1997) reported a 5-fold and a 2-fold increased risks of death from diarrhea and respiratory infections in infants aged birth to 2 months who were given breast milk along with supplements compared with infants who were exclusively breastfed.

The protective influence of breastfeeding is particularly high among children living in rural settlements, particularly with those whose parents are of little or no education, and are denied accessibility to safe drinking water and good toilet facilities (Goldberg, 1984). For instance, in India, exclusive breastfeeding is seen traditionally as a cheap source of food for the children, particularly in the poor households (Nath, Land, and Singh, 1994). On the other hand, infant mortality is high in most Indian homes with very low economic status, thereby; the delay in introduction of supplemental food comes to serve as an adoption through which infant survival can be enhanced through exclusive breastfeeding of their children (Ravilla and Minja, 2000). The reduction of infant deaths attributable to respiratory infections and diarrhea deaths is far below the broad-based beneficial effect of exclusive breastfeeding in prevention of infectious diseases above impact in reducing vulnerability to contaminated food that may have been responsible for the effective protection against diarrhea deaths (Shams, 2013). The risks of ratio of infant deaths estimates that are associated with predominant breastfeeding or non-breastfeeding have been found to be higher for diarrhea deaths than for attributed respiratory deaths (Shams, 2013).

Exclusive breastfeeding as against partial breastfeeding has been identified to safeguard the infant from human immuno deficiency virus transmission from infected nursing mothers to their babies (Cout, 1999). According to a report by WHO (2010), exclusive breastfeeding for the first six months is associated with a 3-4 fold lower risk of HIV transmission as risks between breastfeeding and replacement feeding is fundamentally changed. As it recently reported by UNICEF (2012), about 10-20% of infants born to mothers with HIV without interventions would contract the virus through breast milk if breastfed for two years. However, the risk of postnatal HIV transmission after six weeks of age has been estimated at around 1% per month of breastfeeding (World Health Organization, 2006). More importantly the early initiation of breastfeeding has been reported to influence infant survival as it reduces overall neonatal deaths by 20% and lowers the risk of chronic diseases such as diabetes, heart diseases, obesity, certain cancers, compared with formula feeding in infants (UNICEF, 2012).

2.7 Environmental Risk Factors and Infant Mortality

The World Bank 2001 Annual Reports on environmental hazards states that environmental risk factors account for about one out of every five total burden of disease in low income earning countries of the world. Unsafe water, sanitation, indoor smoke from solid fuels and unhygienic environment accounted for about 90% of infant and child mortality in high mortality developing countries (WHO, 2002). In line with this, environmental risk factors have been discovered to have great negative influence on the survival of the infant child (Anderson et al., 2002). Infant and child mortality are high for children born in rural settlement than those born in urban settlements, while poor environmental conditions are related to high risk of infant and child mortality (Wang, 2003). Research findings have it that two thirds of infant deaths that occurred in the rural plains of Nepal, Bangladesh and North India were recorded in the environment with minimal antenatal or trained obstetric care (Jones and Steketee, 2003).

More so, chemical exposures to environmental pollution such as consumption of contaminated water, unhygienic water disposal, pesticides in agricultural communities, food contamination as well as air and industrial pollution have been established to have significant influence on the risk of congenital anomalies (Dolk and Vrijheld, 2003). Relatively, Buckley, et al. 2003 discovered that mothers who consumed foods that were contaminated with high contents of pesticides and other chemical additives ingested their babies with contaminated breast milk. Therefore, polluted living environment and chemically vulnerable work environment have been discovered not only to be harmful to mothers and their babies but also have some negative effects on their biological characteristics (Dolk and Vrijheld, 2003). Similarly, contaminated water and poor sanitation have been identified as some of the major environmental risk factors that were responsible for chronic diseases among infants and their mothers in a study carried out by Massce and Chris in 2002.

Also, exposure of children to toxic chemicals such as lead discharge from battery recycling operatives, mercury in fish, nitrates, arsenic and fluoride in drinking water have been identified by International Labour Organization [ILO] as the major cause of acute respiratory infections and impaired fertility in nearly 353 million of children ages 5 to 17. According to a report released by WHO (2001), nearly 2 million infants died and children under age five died of dehydration as a result of diarrhea infections. Furthermore, studies have revealed that nearly 500,000 women and children under age five in households where biomass fuel is used in cooking die every year from indoor pollution, largely from acute respiratory infections in India (WHO, 2001). Also, findings from studies have shown that young children and women who are exposed to indoor pollutants are made vulnerable to lower and upper respiratory infections such as colds, sore throats and pneumonia (PRB, 2012; Kirk and Sumi, 2000).

2.8.0 Policy Responses

2.8.1 National Policy on Infant and Young Child Feeding in Nigeria

Infant and young child feeding is an integral part of the overall objective of ensuring the socio-economic wellbeing of all Nigerians. It is in this context that the problem of malnutrition exists and within which the goal and objectives of this policy are derived. Several studies on infant and child survival have the provision of adequate nutrition during infancy and early childhood is a basic requirement for the development and promotion of optimum growth, health and behaviour of the child (WHO, 2001). According to WHO (2001), adequate nutrition is defined as the intake and utilization of enough energy and nutrients to maintain well-being, health and productivity of an individual, in this case, the child. The period of birth to 2 years of age is recognized as a critical period for which adequate nutrition should be provided for the child to achieve optimum development and full potential WHO (2001). Findings from several studies have shown that malnutrition in children manifests as stunting, underweight and wasting in individuals and could be due to deficiencies in macro and micro- nutrients especially vitamin A, iodine, iron, zinc and folic acid (Dykes, 1999; Hector, 2004; Muchina, 2010). Further consequences of malnutrition include impaired immune system leading to significant illnesses, recurrence and severity of diarrhea, acute respiratory infections. In the long run, malnutrition can result in impairment of intellectual performance, and work capacity; it can also have adverse reproductive consequences, delayed mental and physical development as well as death during childhood, adolescence and adulthood (WHO, 2007; Muchina, 2010; UNICEF, 2012; Shams, 2013).

Malnutrition is recognized as a global problem, which, beside weakening the immune system and worsening of illnesses, is the underlying cause of half the deaths of children less than five years old. Of these deaths, 20% are associated with severe and 80% with mild and moderate forms of malnutrition. Well over two-thirds of malnutrition-related deaths occur in the first year of life and are often associated with inappropriate feeding practices WHO (2004).

2.8.2 The National Policy on Infant and Young Child Feeding in Nigeria (2004 Review)

Review of available national policies on Nutrition and Maternal and Child Health revealed gaps in policy provisions on infant and young child feeding. The overall goal of the National Policy on Infant and Young Child Feeding in Nigeria is to ensure the optimal growth, protection and development of the Nigerian child from birth to the first five years of life.

The following are some of specific objectives of the policy:

- To promote, protect and support exclusive breastfeeding in the first six months of life.
- To create and sustain a positive image for breastfeeding throughout the society.
- To empower all women (including women who work outside their homes) to adopt and practice optimal infant feeding.
- To promote the timely introduction of appropriate and adequate complementary foods while continuing breastfeeding up to 24 months and beyond.
- To ensure the provision of specific feeding recommendations for all infants and young children irrespective of their circumstances of birth and health status.
- To promote the provision of appropriate information for nutrition counselling and support for households in the prevention of malnutrition in children.
- To raise awareness on issues affecting infant and young child feeding in Nigeria.
- To provide an enabling environment for mothers, family members and communities to make and implement informed decisions on optimal feeding of infants and young children
- To promote the prevention of mother-to-child transmission of HIV through appropriate and safe measures that ensure optimal infant and young child feeding.
- To ensure that health workers and other care providers have adequate skills and information to support optimal infant and young child feeding including in emergency situations.

In summary, the policy seeks to encourage the practices of exclusive breastfeeding of the infant child by all mothers with the primary objective of improving child and health there by bringing about a substantive reduction in infant and child mortality.

2.8.3 The Nigeria Child’s Protective Policy

The Nigerian Government established the National Child Welfare Committee (NCWC) to formulate a framework for implementing the summit’s goals of the United Nations World Summit (1990) which made imperative for every member of the organization to adopt the Child’s Protective Right policy with the goal to improving the lives of children in every part of the world. Hence, the following measures are being taken by the Government of Nigeria in accordance with the policy to enhance infant and child survival:

- Combating childhood diseases through low-cost remedies and strengthening Primary Health Care ( PHC )and the Basic Health Services Scheme (BHSS);
- prioritising the prevention and treatment of AIDS;
- providing universal access to safe drinking water and sanitary excreta disposal and control of water-borne diseases;
- overcoming malnutrition, including ensuring household food security and developing strategies that include employment and income-generating opportunities;
- dissemination of knowledge; and support for increased food production and distribution.

2.9.0 THEORETICAL FRAMEWORK

Theory of Planned Behaviour

The theory of planned behaviour propounded by Ajzen in 1988 underpins this study. This theory according to Ajzen (1988) posits that individual behaviour is influenced by behaviour intentions where behaviour intention is a function of individual’s attitude towards the behaviour and subjective norms surrounding the execution of the behaviour. Relatively, the choice of a mother to breastfeed her baby exclusively for a complete period of six month as encouraged by UNICEF, ( 2012) and UNO, (2012 or partially is influenced by the intentions of a mother and the conforming norms and values of her immediate environment. Thus, practice of a chosen form of breastfeeding practice by a woman is dependent on the importance that the society place on such behaviour. Ajzen, (1988) perceives behavioural influence as the major control of human action in the society.

According to his theory of planned behaviour, man’s willingness to perform a form of behaviour is influenced by his perceived behavioural intentions which are determined by the perception of his ability to carry out the expected behaviour. Similarly, the choice of breastfeeding practice by a mother is not only subjective in nature but also the impact that the society in which she dwells imposes on or exposes her to. Similarly, the willingness of a mother to accept or reject the exclusive breastfeeding of her baby can be linked to her age, educational attainment, spouse’s level of education, birth interval, adequacy of health care provider, environmental risk factors, age at first birth, occupation, employment status and wealth quintile. Therefore, this study finds the theory of planned behaviour by Ajzen (1988) appropriate as it links man’s behavioural intention and his actual behaviour to the society demands from him and what he personally chooses to gain from adhering or not to the expected behaviour.

However, the choice of a mother to exclusively breastfeed her infant child or not goes beyond her intention or willingness as a result of her perceived benefits, rather the influence of her social environment may have a substantive role to play here. Therefore, cultural setting, social relationships and social environment have great influence on the pattern of breastfeeding practices among mothers, hence, the Social Cognitive Theory needs being discussed.

The Social Cognitive Theory

The social cognitive theory as propounded by Albert Bandura (1986) posits that learning occurs in a social context with a dynamic and reciprocal interaction of the persons, environment, and behaviour. It discusses human behavioural attitude in relation to the effects influenced by personal factors, environmental factors, and continual interaction among people in their community. Therefore, the breastfeeding practice of a mother can be influenced by the perception and attitude of her like or peer. For example, a mother’s perception towards family size can influence her choice of breastfeeding practices where her peers strongly believe that full breastfeeding can be used as a method of controlling fertility. Also, the immediate social environment where a woman resides will go a long way in determining her choice of breastfeeding practice. According to Albert Bandura (1986), one of the reasons that influence the behaviour of a person is the past experiences of the individual, which most times are caused as a result of his interaction with other members of his immediate environment. Therefore, a woman may decide to exclusively breastfeeds her child if she concurs to the impression of the society which supports it, or as a result of the sound health that her child stands to enjoy. Hence, a mother may see exclusive breastfeeding as a reciprocal for the survival of her child.

On the otherhand, the influence of the social environment, social relationship and cultural setting on the choice of breastfeeding pattern adopted by mothers goes beyond the social cognitive theory. It is obvious that a mother’s intention and willingness to exclusively breastfeed her baby is a form of behaviour influenced by her immediate environment. Hence, the two theories complement each other, as they explain the influence of the society, culture and behavioural attitude on mothers’ decision as it relates to their preferred choice(s) of breastfeeding practices.

The reviewed literatures above were limited, these studies did not clearly reveal the association between socio-demographic characteristics of mothers and environmental risk factors in relation to infant mortality, rather the literatures directly explained the association between socio-demographic factors and infant mortality. Also, the reviewed literatures on breastfeeding practices among mothers explored breastfeeding as a mechanism of fertility control, prevention of bleeding, breast and ovarian cancer, rather than explaining the influence of the association between socio-demographic variables and breastfeeding practices on the survival of the infant child. The above limitations on the reviewed literatures have made it imperative for this study to be done. Thus, this study established the socio-demographic characteristics of women and breastfeeding practices as correlates of infant morbidity and mortality which will be useful in policy formulation on infant feeding with the view of promoting infant health and enhancing of infant survival in Nigeria.

2.9.1 Conceptual Framework

According to figure 2.1, infant mortality which is the outcome variable can be influenced by breastfeeding practices (the explanatory variable) and set of intervening variables. Breastfeeding practice has direct influence on intervening variables and also a direct link with infant survival (dependent variable). Infant mortality is captured by prevalence of infanthood diseases and prevalence of infanthood related malnutrition diseases.

The proximate intervening variables include environmental factors which include unsafe water, unhygienic environment, indoor smoke from solid waste and sanitation; the utilization of health care delivery services which include antenatal care, immunization and place of delivery. These intervening variables have direct influence on infant mortality variables. More so, socio-demographic variables, which include age of mothers, educational status of, place of residence, religious belief, wealth quintile, ethnicity, mother’s employment status, mother’s age at first birth, educational attainment of spouse occupation and birth interval, are considered as independent in nature for this study. These socio-demographic variables have direct influence on both the explanatory variable (breastfeeding practices) and the outcome variable (infant mortality).

illustration not visible in this excerpt

Figure 2.1: Conceptual frame work showing the interrelationship between Socio-Demographic Factors, Breastfeeding Practices and Infant Mortality

Source: Author’s work, 2014.

2.10 Study Hypotheses:

1. There is no relationship between socio-demographic characteristic of mothers and their breastfeeding practice.
2. Breastfeeding practice is not associated with infant mortality.
3. There is no relationship between mother’s socio-demographic characteristics and infant mortality.

CHAPTER THREE METHODOLOGY

This chapter discusses the methodology employed in the course of this study. It discusses the study area of this study, the source of data and the information was collected. Also, it explains all the variables used in this study and how the models used in the analysis of data were developed. More so, the chapter addresses the difficulties encountered in the collection of data, and the limitation of data employed in the study.

3.1 Study Area

The history of Nigeria represents the remarkable incidents that transformed and defined the various aspects of the country. Although Nigeria has three main ethnic groups namely Yoruba, Hausa and Igbo, with about 374 identifiable ethnic groups ,the comprehensive history of the country remains incomplete without mentioning the historic reign of the Hausa/Fulani Emirates, the Yoruba Kingdom, the Igbo Kingdom of “Nri” , the Kanem-Bornu empire, the Jukun empire, the Nupe empire, and the Edo Kingdom of Benin. Nigeria has 36 states and a Federal Capital Territory grouped into six geopolitical zones: North central, North East, North West, South East, South-South and South West with 774 legalized local government areas.

The geography of Nigeria is replete with interesting facts and information. The actual geographical area covered by the country is 923,770 sq.km of which the total land is 910, 770 sq.km. The extensive coastline of Nigeria shares an approximate area of 853 km. Nigeria is situated in the western part of Africa and located at latitudes 4o161 and 13o 531 North and longitudes 2o 401 and 14o 411 East is bordered by Niger Republic in the North, Chad Republic in the Northeast, the Republic of Cameroon in the East, and Benin Republic in the West, and to the South it is bordered by approximately 850 kilometres of the Atlantic Ocean, stretching from Badagry in the West to the Rio del Rey in the East. Nigeria is the fourteenth largest country in Africa. The country has a diverse climate and topography which is tropical with distinct wet and dry seasons.

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Figure 3.1: A Map of Nigeria showing the Northern, Southern Regions of the country and the Four States where the study in-depth interviews were conducted.

The country’s population as of 2006 census stood at 140,431, 790 with a natural growth rate estimated at 3.2% annually. Nigeria is the most populous nation in Africa (2006 national population census). The population density is uneven; some areas are densely populated while some are sparsely populated. In terms of health personnel and facilities, Nigeria has approximately 37 physicians, 91 professional/registered nurses, and 64 registered midwives per 100,000 population-members in 2007. Meanwhile, Nigeria’s distribution of healthcare providers differs by geographic and regional factors with more than half of the country’s physician specialist’s working in the southwest while the northern regions exhibit a health worker shortage.

The North Nigeria is decentralized into three geo-political zones comprising North Central, North East and North West. The North Central comprises six states which are: Benue, Kogi, Kwara, Niger, Nasarawa and Plateau. The North East comprises six states namely: Adamawa, Bauchi, Borno, Gombe, Taraba and Yobe. The North West comprises seven states which are: Jigawa, Kaduna, Kano, Katsina, Kebbi, Sokoto and Zamfara. The people of these regions are of diverse ethnic groups, amongst which are the Nupe, Igala, Tiv, Idoma, Igbira, Jukun, Kanuri, Yoruba, Fulani, Hausa. The North Nigeria’s population of about 73.9 million constitutes about 52.6% of the country total with the 2006 census put at over 140.4 million. The population is unevenly distributed across all the states in the north of the country which the most densely populated is Kano with population of over 9.4 million people; follow by Kaduna with population of over 6.1 million people while the two most sparsely populated states are Nasarawa and Taraba with population of about 1.9 million and 2.3 million people respectively.

The Majority of the inhabitants of the North Nigeria shared religious affiliations such as Islam and Christianity, while a very few of the inhabitants are Traditional religious worshippers. The affairs of each state are managed by a governor and by chairman at the local government level. However, there are traditional rulers such as Emirs, Attah, Obas (kings) among others who are assisted by their various chiefs who manage the affairs of their subjects in their different communities. Compared to other regions, the Southwest has the highest number of educated people, and with the highest concentration tertiary institutions. The region is blessed with solid natural resource among which are Limestone, Gold, Tin and Columbite. The region has a fewer concentrations of industries in the country and the majority of the inhabitants are engaged in primary activities, particularly farming, fishing and trading. The major crops grown in this region include millet, maize, yam, Irish and sweet potato, rice, cowpea, cassava, onion, tomato, water melon, groundnut and sorghum.

3.2 Study Design

3.2.1 Secondary Data Source

The data for the study was obtained from Nigeria Demographic and Health Survey (NDHS) data set of 2008. The 2008 NDHS was implemented by the National Population Commission (NPC) from June to October 2008 on a nationally representative sample of more than 36,000 households. All women aged 15-49 in these households and all men aged 15-59 in a sub-sample of half of the households were individually interviewed. The sample for the 2008 NDHS was designed to provide population and health indicators at national, zonal, and state levels. The country was administratively divided into states and each state was subdivided into local government areas, while each local government area was divided into localities. More so, during the 2006 population census, each locality was subdivided into smaller units called census enumeration areas (EAs). The primary sampling unit (PSU), referred to as a cluster for the 2008 NDS, is defined on the basis of EAs from the 2006 EA census frame. The 2008 NDHS sample was selected using a stratified two stage cluster design consisting of 888 clusters, 286 in the urban and 602 in the rural areas. A representative sample of 36,800 households was selected for the 2008 NDHS survey, with a minimum target of 950 completed interviews per state. In each state, the number of households was distributed proportionately among its urban and rural areas. A complete listing of households and a mapping exercise were carried out for each cluster from April to May 2008, with the resulting lists of households serving as the sampling frame for the selection of households in the second stage. All private households were listed. The NPC listing enumerators were trained to use Global Positioning System (GPS) receivers to take the coordinate of the 2008 NDHS sample clusters. In the second stage selection, an average of 41 households was selected in each cluster, by equal probability sampling system. All women aged 15-49 who were either permanent residents of the households or visitors present in the household on the night before the survey were eligible to be interviewed. In a sub-sample of half of the households, all men aged 15-59 who were permanent residents of the households or visitors present in the households on the night before the survey were eligible to be interviewed. Out of total number of 33,385 women of reproductive aged 15-49 interviewed in NDHS 2008, the study utilized information on 12,210 women age 15 to 49 sampled in North of the country who have had at least a birth in the past five years. Information on breastfeeding practices and infant health outcomes was obtained from a section of these women who gave birth in the five years preceding the survey. More so, out of 28,647 children below aged 5 and below information elicited through their mothers in NDHS 2008, the study utilized information on 19,552 sampled in North of Nigeria.

3.2.2 Qualitative Data Collection and Analysis

Primary data was collected through in-depth interviews to supplement and augment the NDHS, 2008 data set. The IDI with was conducted in both English and Hausa Languages respectively. The interviewing of literate interviewees was conducted in English, while the interviewing of the illiterate interviewees was carried out in Hausa Language. The IDIs conducted in both Hausa and English were handled by trained enumerators. The note taking was done in English irrespective of the language employed in collection of the qualitative data. The collected qualitative data in Hausa Language was transcribed and translated into English. Also, there were identifications of words, phrases and sentences with relevance meaning in the course of data analysis. The collected data were analyzed using content analysis method.

The target population for the in-depth interview were women aged 15-49, who have had at least a child within the last five years. Plateau and Kaduna States were purposively selected randomly from North Central and North West respectively. North East 109 infant deaths per 1000 live births is the highest infant mortality rate not only in Northern Nigeria but across the country, hence Gombe and Yobe states were purposively selected from the North East. These randomly selected Four (4) states represented the Three (3) Geo-Political Zones in Northern Nigeria. Ten (10) IDIs was carried out in each of these states. Five (5) IDIs was conducted randomly in rural and urban areas of each of these three states respectively. Population size was used as the criterion for the categorization of urban and rural areas in these selected states.

The research instrument was an interviewer’s guide, which provided greater depth of meaning; sought detailed and open ended responses to questions. The guide contained outlines of topics and a set of general questions; and details that were difficult to capture and this was sought through follow-up questions and probes. The interviewer’s guide for this study was divided into relevant topics which included background information about the respondents; breastfeeding practices (infant feeding); death of infant in recent time; and health care treatment for infanthood related diseases. Forty (40) in-depth interviews were conducted; this was considered adequate because of the qualitative nature of data that was sought and limited resources available for the study. Also, textbooks and handbooks on research support a sample size of between 20 and 30 for in-depth interviews as being appropriate (Population Council, 1998). The obtained information from the qualitative data complemented and strengthened the outcome of the quantitative data.

3.3 Research Variables

- Independent Variables

The key independent variable for this study is Breastfeeding Practices. The Breastfeeding Practices was measured with the following indicators: exclusive breastfeeding, partial or predominant breastfeeding, complementary breastfeeding, as well as time of initiation of breastfeeding. Selected demographic and socio-economic variables were treated as background variables.

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