A comparative study of exclusive breastfeeding between mothers of formal and informal sector workers in Ede north local government area, Osun State Nigeria

INTRODUCTION

Breastfeeding benefits for newborns and infants are well-documented.¹ Breastfeeding provides infants with superior nutritional content that is capable of improving infant immunity and possible reduction in future health care spending.^2,3 The WHO as well as UNICEF called for policies that would cultivate a breastfeeding culture that encourages women to breastfeed their children exclusively for the first 6 months of life and then up to 2 years of age and beyond.⁴ However, based on the WHO global data on infant and young child feeding in Nigeria, 13-36% of children were exclusively breastfed for less than 4-6 months which are far below the 90% level recommended by the WHO.

Achieving Millennium Development Goals 4 (reducing child mortality) and 5 (enhancing maternal health) will depend on successful breastfeeding, which is essential to lowering infant malnutrition.^5-7 Both objectives have not yet been achieved to the desired level of advancement, according to the facts currently available. Several interrelated issues, such as those relating to one’s health, mental well-being, culture, politics, and economics, have an impact on breastfeeding behaviors, including how long one breastfeeds for.^8,9 Education, work, the location of delivery, familial pressure, and cultural norms are some of the factors that affect decisions on the start and length of breastfeeding in low-income countries.¹⁰ The length and practice of exclusive breastfeeding among women who gave birth in health facilities and outside of them has remained low in Nigeria, despite an increase in breastfeeding beginning.¹¹ Early supplemental feeding introduction has an impact on the initiation and sustainability of breastfeeding because it is predicated on false expectations.¹² According to a widely held notion among Yoruba people, supplemental feeding is necessary for babies to easily transition to other meals even though exclusive nursing is advantageous for both mothers and children.¹¹ Personal experiences and networks of support, in addition to societal norms, have an impact on the types and standards of breastfeeding practices. These variables, in large part, put pressure on breastfeeding women, changing how they feel about it over time and space.

Breastfeeding practices and experiences are embodied, contextual, and culturally specific.¹³ Despite the volume of knowledge on breastfeeding practices in Nigeria that is now available, there are few studies that examine the agency of breastfeeding mothers as lived within their socio-cultural environment. Some researchers have previously stated that examining women’ nursing experiences as they are characterized within a social context may indicate the underlying difficulties that must be overcome for the promotion of sustainable breastfeeding practices to be successful.¹⁴ Even though EBF has been the subject of numerous research in Nigeria, little is known about the situation of EBF between mothers of workers in the formal and informal sectors of the country. In order to inform breastfeeding guidance and support for mothers, particularly in the context of the informal sector, this study set out to identify knowledge, practice, and associated factors of exclusive breastfeeding among mothers working in the formal and informal sectors in Ede north local government area, Osun State, Nigeria.

METHODS

Study area

The study was conducted in Ede north local government area, Osun State Nigeria where 60% of the working population is women. Ede is a town in Osun state. Ede is one of the older towns in Yoruba land. It has 2 local governments (Ede north and Ede south). In this study, we worked in Ede north. Ede north has 1 1wards and 18 health care facilities. Ede north has the total population of 117,512. The population of WCBA is 25,853 (22% of total population). It has a primary health centre, a market, pre-primary, primary and secondary educational institutions. The majority of the people are farmers, traders and civil servants. The respondents were nursing mothers with children 0-24 months working in the main informal sector and formal sector jobs in Ede north LGA.

Sample size

Sample size was calculated using the Leslie kish formula: N=Z²×2PQ/d² with 10% prevalence at 5% level of significant. The minimum sample size was based on an EBF prevalence among working women which was 277, confidence interval of 95% (at a Z score of 1.96).

Target population

The target population was nursing traders and corporate working mothers and mothers who breastfed within the last 2 years (April, 2020 to January, 2023) of Buari/lsibo ward, Ede North LGA.

Sampling method

A simple ballot system was used to select Buari/lsibo out of the 11 wards in Ede-north LGA. A simple random sampling method was used to select respondents in this study. Corporate organizations in the area were selected randomly and a cluster sampling method was adopted at each organization.

Inclusion/exclusion criteria

Of this population, breastfeeding mothers who met the study inclusion criteria agreed to participate. attention was focused on mothers breastfeeding currently and who experience of breastfeeding (having more than one child), this helped in examining their knowledge and experience about the practice of exclusive breastfeeding and factors that may influences breastfeeding. Male, children and aged women were excluded.

Instrument

The level of awareness, associated factors, and practice of exclusive breastfeeding as a method of child rearing among informal and formal sector mothers were investigated using three study tools for data collection: a structured questionnaire, a focus group discussion guide, and an in-depth interview.

Methods of data analysis

The quantitative data was analysed using the Statistical Package for Social Scientists (SPSS) version 13. Percentages were used to describe the demographic and socioeconomic situation of the breastfeeding knowledge and practices of the women. Notably, descriptive statistics (number, percentage for categorical variables and mean for continuous variables) and analytic statistics using chi square tests (χ²) to test for the association and/or the difference between two categorical variables were applied. P value equal or less than 0.05 was considered statistically significant. Practice questions were scored and scaled. Total score for practice questions was 17 points. This was dichotomized to the mean point as much as possible; such that respondents with bad practice of exclusive breastfeeding have between 0-8 points and those with good practice had 9-17 points. The findings were presented as both discussions and tables.

At convenient places, in-depth interviews with the nursing women were done in both English and Yoruba. All in-depth interviews were taped on audio recording equipment. Although the second author served as the note-taker, the first author moderated each session. The interviews for employees in the official sector took an average of 47 minutes, whereas those for employees in the informal sector took an hour and ten minutes. Verbatim transcriptions of every interview were made. A specialist in both languages translated and transcribed the Yoruba interviews that were done into English. Afterwards, another linguistics specialist was given access to both papers to verify accurate translation. The transcribed texts were then checked to make sure they were accurately transcribed in order to maintain the sense of the participants’ remarks using the audio taped interviews and the field notes. The texts that were transcribed and translated were all coded. Open and axial coding was both used during the coding process. Based on the main themes of the study, these codes were recorded to create groups. The information in these categories was used to enhance and clarify the quantitative findings.

RESULTS

Demographic characteristics

The mean age of the mother was 27.26 and mode was 28 with 38%. Range of 32, the minimum age was 14 years and the maximum age was 46 years. Most of mothers were Muslim; 181 respondents (63.5%), 100 respondents (35.1%) are Christian while 4 respondents (1.4%) do not signify their religion. Out of 285 respondents, 273 respondents (95.8%) were Yoruba, 2 respondents (0.7%) were Igbo, 8 respondents (2.8%) were kotonu, and 2 respondents (0.7) were Fulani. Out of 285 respondents, 280 (98.2%) respondents are married and 5 (0.8%) respondents were divorced.

Out of 285 respondents, 147 (5.6%) were informal sector worker while 137 (48.1%) respondents were formal sector worker and 1 respondent gave no response. Informal sectors were trader (129 respondents 45.3%), farming (4 respondents (1.4%) and full house wife (14 respondents 4.9%).

Formal sector workers were grouped to: corporate worker (129 respondents 45.3%), students (3 respondents 1.1%), and corper (5 respondents 1.8%). Minimum number of children was 1 and maximum number of children was 7 with the mode of 2 and median of 2. 87 respondents (30.5%) had 2 children; 73 respondents (25.6%) had a child. 61 respondents (21.4%) had 3 children, 39 respondents (13.7%) had 4 children, 14 respondents (4.9%) had 5 children, 1 respondent had 7 children and 6 respondents (2.1%) did not give response pertaining to the number of children. Out of 285 respondents, 8 respondents (2.8%) did not attend school at all, 25 respondents (8.8%) went to primary school, 98 respondents (34.4%) attended secondary school and 154 respondents (54%) attended tertiary institution (Table 1).

Knowledge on exclusive breastfeeding

Out of 285 respondents, 66 respondents (23.2%) did not give any response to the question. 2 respondents (0.7%) had no knowledge at all, 25 respondents (8.8%) had wrong knowledge, while 192 respondents (67.4%) had good knowledge about exclusive breastfeeding.

Good knowledge on exclusive breastfeeding is when respondent says that exclusive breastfeeding is breastfeeding for 6 months without adding any food or water. Wrong knowledge means all other views of exclusive breastfeeding that is different from good knowledge (Figure 1).

Comparing the knowledge of informal sector worker with formal sector worker on exclusive breastfeeding

53 respondents from informal sector did not give response to knowledge questions while 12 formal sector workers did not give response to the knowledge questions. 1 respondent from informal sector did not have any knowledge on exclusive breastfeeding, while 1 respondent from formal sector did not have any knowledge on exclusive breastfeeding. 9 respondents from informal sector had wrong knowledge on exclusive breastfeeding while 16 respondents from formal sector had wrong knowledge on exclusive breastfeeding. 84 respondents from informal sector had good knowledge on exclusive breastfeeding while 184 respondents from formal sector had good knowledge on exclusive breastfeeding (Figure 2). There was a significant difference between knowledge on exclusive breastfeeding among formal sector workers and informal sector workers (χ²=319.71, df=12, p value =0.000). Therefore, the null hypothesis that stated: there was no significant difference in the knowledge of exclusive breastfeeding among informal sector and formal sector workers was rejected and we fail to reject the alternate hypothesis that says: there was significant difference in the knowledge of exclusive breastfeeding among informal sector and formal sector workers (Figure 2).

Practices of exclusive breastfeeding

281 respondents (98.6%) had good practice of exclusive breastfeeding and 4 respondents (1.4%) had bad practice (Table 2).

Comparing the practice of exclusive breastfeeding among formal and informal sector worker

Comparing practice of exclusive breastfeeding among informal sector workers and formal sector workers, all informal sector worker had good practice of exclusive breastfeeding while 3 respondents that signifies to be formal sector worker had bad practice of exclusive breastfeeding and 134 respondent of formal sector worker had good practice of exclusive breastfeeding (Figure 3). There was a significant difference between knowledge on exclusive breastfeeding among formal sector workers and informal sector workers (χ²=72.95, df=2, p value =0.000). Therefore, the null hypothesis that stated: there was no significant difference in the practice of exclusive breastfeeding among informal sector workers and formal sector workers was rejected and we fail to reject the alternate hypothesis that said: there was significant difference in the practice of exclusive breastfeeding among informal sector and formal sector workers (Figure 3).

Factors affecting exclusive breastfeeding

Out of 285 respondents, 4 respondents (1.4%) did not respond to the question, 10 respondents (3.5%) didn’t know if they lactate well or not, 44 respondents (15.4%) said they do not lactate well, while 227 respondents (79.6%) said they lactate well. Out of 285 respondents, 5 respondents (1.8%) did not respond to the question, 54 respondents (18.9%) said their job hinders exclusive breastfeeding, while 226 respondents (79.3%) said their job does not hinder exclusive breastfeeding. This question is only applicable to only formal sector workers. 1 respondent (0.4%) reported that she have a day leave, 3 respondents (1.1%) reported that they have 2 weeks leave, 34 respondents (11.9%) reported that they have 3 weeks leave, 44 respondents (15.4%) reported that they have 4 weeks leave, 8 respondents (2.8%) reported that they have 6 weeks leave, 22 respondents (7.7%) reported that they have 2 months leave, 34 respondents (11.9%) reported that they have 3 months leave, 3 respondents reported that they have 2 years leave (1.1%), 10 respondents (3.5%) reported that they have no leave. Out of 285 respondents, 3 respondents (1.1%) did not respond to the question, 70 respondents (24.6%) said they need to go to school while breastfeeding, while 212 respondents (74.4%) said they need to go to school while breastfeeding.

Out of 285 respondents, 2 respondents (0.7%) did not respond to the question, 4 respondents did not know whether their baby is sucking well or not, 227 respondents (79.6%) said their baby is slicking well, while 52 respondents (18.2%) said their baby is not sucking well. This question was only applicable to formal sector works. 148 respondents (51.9%) were not applicable to this questions, 8 respondents (2.8%) did not respond to this question, 32 respondents (11.2%) did not know if there is crèche closer to their place of work or not, 84 respondents (29.5%) said there is a crèche closer to their place of work, while 13 respondents (4.6%) said there is no crèche closer to their place of work. This question was only applicable to formal sector works. 148 respondents (51.9%) were not applicable to this question, 8 respondents (2.8%) did not respond to this question, 55 respondents (19.3%) made use of a crèche, and 74 respondents (26%) did not make use of any crèche (Table 3).

Comparing the factors that affect practices of exclusive breastfeeding among informal sector workers and formal sector workers

Comparison of factors affecting exclusive breastfeeding with practice of exclusive breastfeeding, demographic characteristics such as number of children, occupation, educational status, and factors affecting exclusive breastfeeding such as lactation status, knowledge of exclusive breastfeeding, job hindrance, maternity leave, need to go to school, sucking ability of a child, crèche availability and crèche utilization by using chi-square test with the level of confidence 95% and the p value was set at p value <0.05 (Table 4).

DISCUSSION

The most crucial nutritional intervention to prevent child diseases and death is optimal breastfeeding, especially exclusive. EBF is regarded as a crucial practice for achieving the 2030 sustainable development goals, in particular SDGs 2 and 3. These goals are to end world hunger and improve nutrition, as well as SDG 3 to reduce child and maternal mortality and improve health for all people worldwide.¹⁵ Infants can receive the best nutrition by being breastfed. It has all the nutrients newborns require for healthy growth and development, as well as antibodies that can shield them from a variety of ailments common to children.¹⁵ Hence, the decision to breastfeed exclusively is a mother factor that should be taken into consideration.¹⁶ The primary aim of this study was to examine and compare the knowledge, practices and factors affecting exclusive breastfeeding among informal sector workers and formal sector workers in Ede north local government. Thus, comparative findings from this study revealed that most mothers in formal sector were well-informed about the benefits of exclusive breastfeeding relative to the informal sector nursing mothers. Similarly, a high degree of awareness of exclusive breastfeeding by nursing mothers was also found in a prior study by Piro and Ahmed, as well as in Akinola et al study on awareness and importance of colostrum among nursing mothers.^17,18

The result of this survey showed that 64.4% of respondents have good knowledge about exclusive breastfeeding. In accordance to this study, a study carried out among mothers in Saudi Arabia showed that 65.7% respondents also had good knowledge on exclusive breastfeeding. In contrary to this study, a study was carried out in Ethiopia, 90.8% of the respondents had good knowledge.¹⁹ Also finding in worked Gebeyehu, 74.2% had good knowledge.²⁰ Looking at the knowledge of exclusive breastfeeding among informal sector workers and formal sector workers, formal sector had more knowledge about exclusive breastfeeding than the informal sector workers. Also, there was a significant difference between knowledge and occupation.

The result of this study showed that 281 respondents (98.6%) have good practice of exclusive breastfeeding. This study supports WHO recommendation of about 90% prevalence of exclusive breastfeeding. A study contrary to this study was carried out in Bayelsa: just 26.9% have good practice.²¹ Study carried out in Bayelsa is also contrary to WHO recommendation. Nonetheless, among informal nursing mother, the practice of EBF in the research area is comparatively high as related to formal nursing mother. This can depend on some working factors without maternal leave. Report shows only 13% out of every six children in Nigeria are solely breastfed, according to the Nigeria demographic Health Survey, while 87% out of every six Nigeria infants receive supplemental liquids or foods.¹¹ However, looking at the practice of exclusive breastfeeding among informal sector workers and formal sector workers, informal sector workers have more good practice of exclusive breastfeeding than formal sector workers. This shows that there is a significant relationship between practice of exclusive breastfeeding and occupation.

Also, in this study, there are a lot of factors affecting exclusive breastfeeding among formal sectors and informal sectors nursing mothers. These include: lactation of mothers, job hindrances, number of children, educational status, occupation, maternity leave, need to go to school, baby’s sucking ability, knowledge of exclusive breastfeeding, crèche availability and crèche utilization.

By using cluster sampling, the researcher was able to obtain a significant sample from the region they visited, ensuring a balanced representation of different racial and ethnic groups of people. The fact that it only applied in one location limited its ability to be generalized. The findings, however, may still be applicable to different areas of the country and can be used to offer light on how both formal and informal employment affect exclusive breastfeeding. The study’s cross-sectional design precluded time attributions from being inferred from the data. It does pave the path for future research using more robust study designs capable of inferring temporal connections. Another limitation is that our study used a mother who had only nursed for the preceding 24 hours to assess EBF. Due to the chance that the infant had more meals, the true prevalence of EBF may have been overestimated. Because we visited families to gather data, it's possible that we only discovered mothers who worked near to their homes, where they may have encountered a different work environment than those who worked elsewhere.

CONCLUSION

Based on the findings, breastfeeding mothers are faced with multiple challenges as they strive to practice exclusive breastfeeding. Thus, scaling up of exclusive breastfeeding among formal nursing mothers requires concerted efforts at the various levels of Nigerian society. The practice rate of EBF was low among the mothers in our study despite their increased knowledge on EBF, and the factors identified such as maternity leave and as well as job hindrances influencing its practice may have important implications for breastfeeding intervention programmes. Activities to promote EBF should therefore be intensified and focused on formal nursing mothers in which poor breastfeeding practices exist. Support for the mothers is also necessary.

Recommendations

In order to improve EBF among mothers working in the informal sector, the study suggests the following;

To government

By upholding the principles of the Employment Act, efforts should be made to protect, promote, and support breastfeeding among working women in both the formal and informal sectors. The government should educate mothers who work in the formal sector about their entitlement to the 60-day leave period that is now available, which gives them time to establish breastfeeding in the first few months of a child’s life.

To health facilities

Services for prenatal care should concentrate on encouraging mothers’ intentions to practice exclusive breastfeeding, since this has been demonstrated to be a significant predictor of EBF among women working in the unorganized sector. At ANC, moms who work in the unorganized sector can receive specialized counselling on how to handle breastfeeding difficulties at their workplaces. Even if these moms are away from their children throughout the day for work, encouraging them to express breast milk will help them reach the 6-month mark of exclusive breastfeeding.

To employers in the formal sector

Regardless of their position at work, employers in the formal sector should be made aware of the advantages of optimal baby feeding and the regulations governing employee access to maternity leave and breastfeeding support through counselling and health education.

To breastfeeding mothers in the formal sector

The benefits of exclusive nursing for children fewer than 6 months should be made known to mothers during prenatal visits so that they can make an educated choice regarding exclusive breastfeeding.

Further research

Further studies are required to study workplaces in order to develop and test context-specific treatments to enable mothers who work in the informal sector in continuing to exclusively breastfeed their children.

ACKNOWLEDGEMENTS

We appreciate the help from the data collectors and the volunteers who gave up their valuable time to participate in this study. For allowing us to perform this study, we are grateful to Adeleke University’s department of public health. We want to express our gratitude to our department of public health colleagues who helped this study take shape in a positive way.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: The study was approved by the Institutional Ethics Committee

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