|Year : 2018 | Volume
| Issue : 3 | Page : 855-861
The barriers to breastfeeding among women: a single-center experience
Hala M Shaheen1, Nagwa N Hegazy1, Sara S.A Sakr2
1 Department of Family Medicine, Faculty of Medicine, Berket El-Sabaa Health Administration, Berket El-Sabaa City, Egypt
2 Department of Family Medicine, Berket El-Sabaa Health Administration, Berket El-Sabaa City, Egypt
|Date of Submission||23-Dec-2017|
|Date of Acceptance||03-Mar-2018|
|Date of Web Publication||31-Dec-2018|
Sara S.A Sakr
Department of Family Medicine, Berket El-Sabaa Health Administration, Berket El-Sabaa City, Menoufia Governorate
Source of Support: None, Conflict of Interest: None
To estimate the prevalence of exclusive breastfeeding (EBF) and to identify barriers to breastfeeding among the studied mothers in Berket El-Sabaa District, Menoufia Governorate, Egypt.
Human breast milk is the ideal and unique food for infants. However, most infants today still do not receive the full benefits of breastfeeding. Low breastfeeding rates during the first 6 months imply that mothers are constantly faced with multiple barriers to continue breastfeeding.
Patients and methods
The study was a cross-sectional study. It was conducted on 370 mothers of infants aged 2–6 months. All participants were interviewed using a predesigned questionnaire included personal data about mothers and their youngest infants, socioeconomic status, and barriers of initiation and EBF.
Nearly two-thirds of the mothers (60%) came from the rural area, and 55.1% were housewives. Nearly two-thirds of mothers' families (61.6%) had moderate socioeconomic status. Only 28.6% of infants were exclusively breastfed. The most prominent barriers to EBF were lack of health education about breastfeeding (84.1%) (P ≤ 0.001), hungry infant (43.2%) (P ≤ 0.001), nipple fissures and soreness (40.2%) (P = 0.002), easiness of artificial feeding (39.4%) (P ≤ 0.001), and belief of insufficient milk supply (37.9%) (P ≤ 0.001).
Prevalence of EBF is low among studied group. Many barriers obscure breastfeeding making it nonexclusive. Awareness should be raised about benefits of EBF for the first 6 months of infant's life and breastfeeding problems and how to overcome them.
Keywords: barriers, breastfeeding, exclusive, initiation, prevalence
|How to cite this article:|
Shaheen HM, Hegazy NN, Sakr SS. The barriers to breastfeeding among women: a single-center experience. Menoufia Med J 2018;31:855-61
|How to cite this URL:|
Shaheen HM, Hegazy NN, Sakr SS. The barriers to breastfeeding among women: a single-center experience. Menoufia Med J [serial online] 2018 [cited 2019 Jan 22];31:855-61. Available from: http://www.mmj.eg.net/text.asp?2018/31/3/855/248766
| Introduction|| |
Breastfeeding is recognized as the most appropriate mode for infant feeding. Providing several short-term and long-term benefits for both infants and mothers.
According to WHO recommendations, children should be exclusively breastfed (EBF) during the first 6 months of life on demand, with continued breastfeeding along with appropriate complementary food up to 2 years of age or beyond. Breastfeeding initiation should be within the first hour of life. However, currently fewer than 40% of infants under 6 months of age are EBF worldwide.
Most infants today still do not receive the full benefits of breastfeeding, leaving millions at unnecessary risk of illness and death, and most health workers lack the skills and knowledge needed to help mothers improve their feeding practices.
Breastfeeding rates declined sharply after the 1920s as a result of the introduction of evaporated cow's milk followed by the mass introduction of formula milk products. At present, wide variations in breastfeeding rates exist, and overall rates are typically low.
The main barrier to EBF is the lack of knowledge about proper infant feeding practices in addition to lack of supportive environment. Traditional infant feeding practices were often influenced by myths and misconceptions.
The American Academy of Family Physicians has long supported breastfeeding. All family physicians have a unique role in supporting and promoting breastfeeding.
In the present study, the aim was to assess the prevalence of breastfeeding and identify barriers to breastfeeding among mothers in Berket El-Sabaa District, Menoufia Governorate, Egypt.
| Patients and Methods|| |
The study was a cross-sectional study conducted in the context of time frame of 19 months (starting from first March 2016 to the end of September 2017). The target population is mothers of infants aged 2–6 months attending vaccination sessions in Berket El-Sabaa District, Menoufia Governorate, Egypt.
The study was approved by the Ethical Committee of the Faculty of Medicine, Menoufia University. An official permission letter was obtained and directed to the administrators in Berket El-Sabaa District. All participants of the study were volunteers. Oral consents were provided by all participants in the study after illustration of purposes of this study. It was emphasized that all data collected were strictly confidential, and the data were used for scientific purpose only.
Sample size was calculated using Epi Info version 7 (Centers for Disease Control and Prevention (CDC) in Atlanta, Georgia (US)), based on the percentage of mothers' perception of milk insufficiency (33.9%), using the following equation:
where P is the percentage of mothers' perception of milk insufficiency (33.9%); Z, a percentile of standard normal distribution determined by 95% confidence level = 1.96; and Δ, the width of the confidence interval = 5%.
According to the statistics in healthcare management in Berket El-Sabaa in 2015, the total number of pregnant mothers in the previous year of the study (2015) at all healthcare sites at Berket El-Sabaa District was 5858 mothers, so the calculated total sample size is 325 mothers, which was increased to 380 mothers to avoid dropout and repetition during the procedure of the study. The number of mothers who refused to be interviewed was 10. So, the total number of mothers who participated in the study was 370.
Inclusion criteria were mothers of infants aged 2–6 months and who accepted to participate in the study.
Exclusion criteria were mothers who had participated in the study before, who do not have reliable information, or who refused to participate in the study.
The mothers were interviewed face to face using a predesigned questionnaire that was divided into three sections:
- Personal data of mothers (age, sex, education, occupation marital status, and residence) and their youngest infants
- Socioeconomic standard was determined according to the scoring system of Fahmy et al. (a high level was indicated as ≥70%, a medium level as 40 to <70%, and a low level as <40%)
- Breastfeeding pattern of the youngest infant, barriers to initiation of breastfeeding (e.g., pain, tiredness, lack of knowledge, delayed or no milk production, painful breast, failure to attach, and embarrassment), and barriers to EBF, including maternal barriers (e.g., nipple problems, breast engorgement, and insufficient milk supply), infantile barriers (e.g., hungry baby, insufficient weight gain of the infant, admission to NICU, oral problems, rejection of breastfeeding, and pediatric prescription of artificial feeding), and beliefs and attitude (e.g., misconception that artificial milk is more beneficial, family advice, new pregnancy, multiple births, pacifier usage, contraception is a reason for milk insufficiency, breastfeeding is embarrassing, and work).
A pilot study was conducted on 10 attendees to the child care center (not included in the final results of the study) for the following:
- Evaluate the adequacy of the study tools (questionnaire and sheets), content, language, time consumption, availability of the needed data, and feasibility of the research methods.
- Determine the time needed for filling the questionnaire.
- Explore the potential obstacles and difficulties that confront the execution and flow of work.
Statistical analysis of the study was conducted by statistical package for the social sciences (SPSS) version 20 on IBM compatible computer (SPSS Inc., Chicago, Illinois, USA). Two types of statistics were done: descriptive statistics (data were expressed as numbers and percentage) and analytic statistics (which included χ2-test and Fisher exact test that were used to study association between two qualitative variables). P value of less than 0.05 was considered statistically significant.
| Results|| |
A total of 370 mothers answered the questionnaire. Most studied mothers (72.4%) aged from 20 to 30 years, and nearly two-thirds of them (60%) came from the rural area. Regarding the mother's education, approximately two-thirds of the mothers (63.8%) had intermediate educated (primary, preparatory, and secondary education). More than half of the mothers (55.1%) were housewives. Nearly two-thirds of mothers' families (61.6%) were of moderate socioeconomic status. It was found that EBF rates were more among mothers aged 20–30 years (75.5%), with intermediate educational level (58.5%), housewives (69.8%), multipara (83.0%), moderate socioeconomic standard (55.7%), mothers who received health education about breastfeeding and were trained about appropriate positioning (62.3%), mothers who got their information about breastfeeding from medical staff (62.3%), and mothers who initiated breastfeeding early within the first hour of labor (77.4%) [Table 1].
|Table 1: Feeding practice of the youngest infant in relation to some variables|
Click here to view
More than half of the infants (54.6%) were mixed fed, 28.6% were EBF, and only 16.8% of the infants were not breastfed [Figure 1].
Most mothers (58.9%) initiated breastfeeding late after delivery (not during the first hour after labor). Only 2.7% of mothers never breastfed their infants. Tiredness, belief of no or insufficient milk, pain owing to labor, inadequate knowledge about breastfeeding importance during first hour after labor, painful breast during nursing, embarrassment to nurse, hospitals offering bottle of artificial milk or herbal drink, and failure of attachment to the nipple (89.9, 86.2, 78.9, 59.6, 53.2, 47.7, 45, and 43.1%, respectively) were the barriers to early initiation of breastfeeding [Figure 2].
|Figure 2: Barriers to early initiation of breastfeeding (not during the first hour after labor).|
Click here to view
Barriers to EBF were lack of health education about breastfeeding and its benefits (84.1%) (P ≤ 0.001), hungry infant (43.2%) (P ≤ 0.001), nipple fissures and soreness (40.2%) (P = 0.002), easiness of artificial feeding (39.4%) (P ≤ 0.001), perceived insufficient milk supply (37.9%) (P ≤ 0.001), tiredness during breastfeeding (37.5%) (P ≤ 0.001), pediatrician prescription for artificial milk or other supplements (36.4%) (P ≤ 0.001), considering artificial milk is more beneficial than mother's (34.1%) (P ≤ 0.001), work of the mother (33.7%) (P ≤ 0.001), advice from family and friends to use supplements (31.8%) (P ≤ 0.001), infant rejection of breastfeeding (31.1%) (P ≤ 0.001), breast engorgement or abscess (29.5%) (P ≤ 0.001), weight gain of the infant is not satisfactory (28%) (P ≤ 0.001), pacifier use (26.5%) (P = 0.01), mother use herbal drinks to relieve colic (18.9%) (P ≤ 0.001), contraceptive pills usage made breast milk dry (18.2%) (P ≤ 0.001), breastfeeding is embarrassing and restricted mother from daily activities (11.7%) (P = 0.003), admission of the infant to NICU (9.8%) (P = 0.03), and oral candidiasis (6.1%) (P ≤ 0.001) [Table 2]).
|Table 2: Barriers to breastfeeding in relation to feeding practice of the youngest infant|
Click here to view
Logistic regression analyses of factors affecting non-EBF were as follows: having caesarian delivery [odds ratio (OR = 31.9)], being working women (OR = 15.5), moderate socioeconomic standard (OR = 32.4), being primigravida (OR = 15.6), and high socioeconomic status (OR = 13.1) ww [Table 3].
|Table 3: Logistic regression analysis of factors affecting the nonexclusive breastfeeding|
Click here to view
| Discussion|| |
The current study confirms that prevalence of EBF was seen in ∼28.6%, whereas 54.6% were mixed fed, and only 16.8% of the infants were not breastfed. This finding was supported by El-Zanaty who found that only 40% of children under 6 months were EBF, 54% received mixed feeding, and only 7% were not breastfeed.
The current study found that prevalence of initiation of breastfeeding within the first hour after labor is 2.7%. This was much less than the percentage of the study of Mohamed and colleagues, which found that 20.1% initiated breastfeeding within the first hour after labor, also less than the percentage of 10.4% according to Al Ghwass and Ahmed.
According to the present study findings, most women reported barriers that influenced the initiation of breastfeeding within 1 h of birth as tiredness, pain, perception of insufficient milk product, and did not have enough knowledge about the initiation time of breastfeeding. These findings were similar to the findings of Raffle et al. who stated that pain of mothers and perception of infants not receiving adequate amounts of breast milk had a negative effect on breastfeeding decisions.
There was significant association between prevalence of EBF and multiple factors. In this study, it was more in mothers aged 20–30 years (75.5%). These results were in contrast to Woldie et al. who mentioned that the women least likely to breastfeed are those who are young. However, this result was supported by Gijsbers et al. who showed that younger maternal age was associated with a longer duration of breastfeeding.
EBF rates had no significant relation with residence of the mothers in this study. However, according to the study by Mohamed et al., it was found that mothers from urban areas were less likely to practice EBF than those from rural areas.
EBF was more prevalent in those with intermediate educational level (58.5%), and this finding was in contrast with the study by Agampodi et al. who indicated that additional mother education did not significantly affect breastfeeding rate.
Housewives (69.8%) were more likely to breastfeed their infants exclusively, and this finding was supported by Setegn et al. who showed that unemployed mothers were about five times more likely to breastfed exclusively as compared with employed mothers.
Mothers who delivered their infants vaginally had higher prevalence of EBF (62.3%). This finding was similar to the study by Saeed et al. who stated that women with cesarean deliveries had a definitely greater chance of having problems of breastfeeding owing to pain and discomfort associated with cesarean birth.
EBF rates were more in multipara (83.0%). This finding coincides with studies done in the UK which affirmed that breastfeeding duration increases with increasing parity, which might be related to previous breastfeeding experiences. However, according to the study by Abada et al., it found that primiparous women are less knowledgeable and skillful in breastfeeding, hence, they will usually seek help from healthcare professionals who generally promote breastfeeding. Nevertheless, in the study by Ekström et al., it was asserted that parity had no significant influence on duration of breastfeeding.
EBF was more among mothers of moderate socioeconomic standard (55.7%), and this finding was supported by Rojjanasrirat and Sousa who stated that lower breastfeeding rates were found to occur in the lower income brackets.
According to this study, it was found that EBF rates were more among mothers who received health education. This finding was supported by Semenic et al. study which found that women who receive prenatal care and attend prenatal educational classes are more likely to have breastfeeding duration levels closer to the recommendation by the WHO.
In this study, the main source of information of mothers about breastfeeding was from their mothers and mothers-in-law (58.9%). This was supported with Arora et al. who found that the mother's primary sources of information are their family (33.9%).
The early initiation time of breastfeeding was significantly associated with high EBF rates, and this finding is similar to other finding of Setegn et al. who stated that mothers who initiated breastfeeding within 1 h of birth were two times more likely to practice EBF than mothers who initiated after 1 h. However, El-Mougi et al. found that early start of breastfeeding had no effect.
In this study, the leading barriers to EBF were lack of health education about breastfeeding and its benefits, hungry infant, nipple fissures, easiness of artificial feeding, and belief of insufficient milk supply. In the same line, these findings were also in congruence with the study by Kirkland and Fein. The following four leading reasons women often report for breastfeeding discontinuation: breast discomfort (including nipple pain); perceived insufficient milk supply; a negative family or healthcare support system; or conflicts with other activities, such as employment. In addition, Otsuka et al. showed that 54% of mothers give an inadequacy of breast milk as the reason for giving formula before 6 months, and this finding may attribute to many women who utilize infant satisfaction cues as their main indication of milk supply, and many women do not evaluate actual milk supply.
Study limitations included traditional idea, concept, and expectation, and also, interruptions during interviewing the cases.
Based on the finding of the current study, the following recommendations are suggested: primary healthcare physician should use evidence-based strategy in diagnosing and management of breastfeeding problems. Awareness should be raised about the magnitude of the problem, risk factors of breastfeeding problems, and how to overcome them.
| Conclusion|| |
The study concluded that there was a low prevalence of EBF for the first 6 months of infant's life as recommended by WHO. Many barriers prevented the mothers from EBF their infants. The most common barriers were lack of health education about breastfeeding and its benefits, hungry infant, considering artificial feeding is easier and more comfortable, belief of insufficient milk supply, and tiredness during breastfeeding.
Moreover, this study showed that EBF rates are more in mothers aged 20–30 years, mothers with intermediate educational level, employed mothers, multipara mothers, mothers with moderate socioeconomic standard, and mothers who initiated breastfeeding early after the first hour of labor.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
World Health Organization. Infant and young child feeding: model chapter for textbooks for medical students and allied health professionals
. Geneva: Infant and young child feeding: model chapter for textbooks for medical students and allied health professionals; 2009.
World Health Organization. Exclusive breastfeeding for six months best for babies everywhere
. Geneva: World Health Organization; 2011.
United Nations Children's Fund (UNICEF). Celebrating the Innocenti Declaration on the Protection, Promotion and Support of Breastfeeding: Past Achievements, Present Challenges and Priority Actions for Infant and Young Child Feeding
ed. Italy: UNICEF Innocenti Research Centre, Florence; 2006.
Hector DJ. Complexities and subtleties in the measurement and reporting of breastfeeding practices. Int Breastfeed J 2011; 6
Thet MM, Khaing EE, Diamond-Smith N, Sudhinaraset M, Sandar OO, Aung T. Barriers to exclusive breastfeeding in the Ayeyarwaddy Region in Myanmar: Qualitative findings from mothers, grandmothers, and husbands. Appetite 2016; 96
Wright CM, Parkinson KN, Drewett RF. Why are babies weaned early? data from a prospective population based cohort study. Arch Dis Child 2004; 89
Motee A, Ramasawmy D, Pugo-Gunsam P, Jeewon R. An assessment of the breastfeeding practices and infant feeding pattern among mothers in Mauritius. J Nutr Metab 2013; 2013
Fahmy SI, Nofald LM, Shehatad SF, El Kadyb HM, Ibrahim HK. Updating indicators for scaling the socioeconomic level of families for health research. J Egypt Public Health Assoc 2015; 90
El-Zanaty F. Egypt demographic and health survey
. Cairo, Egypt: MOHP and El-Zanaty and Associates; 2014. 26–31.
Mohamed SH, Zaki NA, Thabet AM. Barriers of initiation and exclusive breast feeding among infants. IOSR J Nurs Health Sci 2016; 5
Al Ghwass MME, Ahmed A. Prevalence and predictors of 6-month exclusive breastfeeding in a rural area in Egypt. Breastfeed Med 2011; 6
Raffle H, Ware L, Borchardt A, Strickland H. Factors that influence breastfeeding initiation and persistence in Ohio's Appalachian region
. Athens, OH: Voinovich School of Leadership and Public Affairs at Ohio University; 2011. pp. 6–96.
Woldie T, Kassa A, Edris M. Assessment of exclusive breast feeding practice and associated factors in Mecha district, North west Ethiopia. Sci J Public Health (Bangkok) 2014; 2
Gijsbers B, Mesters I, Knottnerus JA, van Schayck CP. Factors associated with the duration of exclusive breast-feeding in asthmatic families. Health Educ Res 2007; 23
Agampodi SB, Agampodi TC, de Silva A. Exclusive breastfeeding in Sri Lanka: problems of interpretation of reported rates. Int Breastfeed J 2009; 4
Setegn T, Belachew T, Gerbaba M, Deribe K, Deribew A, Biadgilign S. Factors associated with exclusive breastfeeding practices among mothers in Goba district, south east Ethiopia: a cross-sectional study. Int Breastfeed J 2012; 7
Saeed A, Bani A, Al-Murshed K. Mothers practices during pregnancy, lactation and care of their children in Riyadh, Saudi Arabia. Saudi Med J 2011; 23
Agboado G, Michel E, Jackson E, Verma A. Factors associated with breastfeeding cessation in nursing mothers in a peer support programme in Eastern Lancashire. BMC Pediatr 2010; 10
Abada TS, Trovato F, Lalu N. Determinants of breastfeeding in the Philippines: a survival analysis. Soc Sci Med 2001; 52
Ekström A, Widström AM, Nissen E. Duration of breastfeeding in Swedish primiparous and multiparous women. J Hum Lact 2003; 19
Rojjanasrirat W, Sousa V. Perceptions of breastfeeding and planned return to work or school among low-income pregnant women in the USA. J Clin Nurs 2010; 19
Semenic S, Loiselle C, Gottlieb L. Predictors of the duration of exclusive breastfeeding among first-time mothers. Res Nurs Health 2008; 31
Arora S, McJunkin C, Wehrer J, Kuhn P. Major factors influencing breastfeeding rates: mother's perception of father's attitude and milk supply. Pediatrics 2000; 106
El-Mougi M, Mostafa S, Osman NH, Ahmed KA. Social and medical factors affecting the duration of breast feeding in Egypt. J Trop Pediatr 1981; 27
Kirkland V, Fein S. Characterizing reasons for breastfeeding cessation throughout the first year postpartum using the construct of thriving. J Hum Lact 2003; 19
Otsuka K, Dennis C, Tatsuoka H, Jimba M. The relationship between breastfeeding self-efficacy and perceived insufficient milk among Japanese mothers. J Obstet Gynecol Neonatal Nurs 2008; 37
[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3]