Breastfeeding Practices among Health Professionals in Tertiary Hospital in Nairobi, Kenya

Introduction

There is a universal consensus about the fundamental importance of breastfeeding for children’s adequate growth and development. One should not forget the maternal benefits. These benefits extend well beyond basic nutrition and health to include social and economic ones that extend up to adulthood. These benefits are some of the key interventions that will help in achieving the sustainable development goals [1, 2, 3, 4].

Exclusive breastfeeding for 6 months was endorsed by the world health assembly in 2001 [5, 6]. The Lancet Series of 2003 estimated that exclusive breastfeeding could save 13% of all deaths of children younger than five years of age [7]. Kramer & Kakuma 2012 has since reviewed this and the protective effects of breastmilk still stand [8]. However global exclusive breastfeeding rates have remained low. In 2010 the global rate of exclusive breastfeeding was at 39% but the target is 50% which is expected by year 2025 [9]. By 2014 Kenya’s rate of 61% was above the 2025 global target [10].

It is generally assumed that health care professionals are knowledgeable and thus their exclusive breastfeeding rates for six months should be high. Their knowledge and practices is likely to influence how they handle their clients [11]. The focus of many studies has been on how health care professionals assist their clients with few focusing on the health professional knowledge and practices for their own children. The reported exclusive breastfeeding rate among health care professionals is 11- 58% [12, 13, 14, 15, 16].

Kenyatta National Hospital is a designated baby friendly hospital but no studies have been done to evaluate the breastfeeding experience of health care professionals working within the institution. The current study was carried out to establish the breastfeeding practices during the first six month among female doctors (residents) and nurses.

Results

Of the 160 questionnaires issued, 150 (93.8%) were returned. Of these 139 (93.7%) were valid, and 11 were wrongly filled. The valid questionnaires comprised of 49 (35%) residents and 90 (65%) nurses. The characteristics of the respondents are shown in table 1. Most of the doctors (89.4%) fell between ages 26 to 35 years compared to the nurses who were a little more evenly spread out. Median age for doctors was 31 years the one for the nurses was 35 years; this difference was significant p= 0.00. Generally 89.2% were married. Caesarean section delivery was high at 39.6%.

The medical departments (paediatrics and internal medicine) had the highest number at 52.5% followed by the surgical disciplines at 41.0% as shown in table 2. Most of the doctors were in the medical departments, there was no doctor in the surgical discplines.

Cumulatively, the total number who exclusively breastfed for the first three months was 99.3%, this proportion reduced to 94.9% at four months, and 64.2% at 5 months. However, by the sixth month only 29.2% had managed to exclusively breastfeed. The median exclusive breastfeeding period was 5 months. There were no differences between the doctors and nurses at each month.

As shown in table 3, initiation within an hour of birth was done by 69.6% of respondents. Those who delivered by Caesarean section were more likely to have delayed initiation p-value = 0.00. Twenty five respondents (22.1%) gave prelacteal feeds; of these 21 had delivered via caesarean section.

Table 3: Initiation of breastfeeding and use of prelacteal feeds in relation to mode of delivery Other breastfeeding practices are shown in tables 4a and 4b. About eighty two percent (82.3%) intended to breastfeed exclusively for 5-6 months with the intention being higher among doctors. Fewer numbers (66.3%) thought the 6 month exclusive breastfeeding duration was feasible yet 94.2% had recommended it to others. Even though 46% did not have consideration on work schedule when they returned back to work it is gratifying that 75.5% had support from colleagues. Some (60.5%) Hindrances towards exclusive breastfeeding that they had as a healthcare professionals working at KNH included: Long working hours, lack of rooms to express milk; Lack of time and space to breastfeed; Short maternity leave; Heavy work.

made their own adjustment. However there was a perceived decrease in breastmilk supply in 81.8%. Only 34.9 % had had any post basic breastfeeding training.

Table 4a: Summary of breastfeeding practices.

Table 4b: Summary of breastfeeding practices.

Discussion

The current study concentrated on the practices during the first six months which is the period of exclusive breastfeeding. The response rate was high at 93.8%. This is in contrast to the 45-68% rate reported from other studies [17, 18, 19]. This is most likely due to the fact that our study was within the same institution with personal contact of the respondents rather than mail, and there was little lag time between the issuing of the questionnaire and collection.

Studies on exclusive breastfeeding vary according to the method of data collection. The WHO recommended collection is a 24 hour recall for all babies under 6 months of age [20]. But there is another way of looking at it in that mothers are interviewed after six months and only those who completed 6 months of exclusive breastfeeding are counted [21, 22]. The two rates are likely to be different. In our study the rate at 6 months was 29.2%. However the rates were high during the first four months that are equivalent to the official 3 months maternity leave plus one month annual leave in Kenya [23]. There after the rates dropped considerably to a rate of 29.2% at 6 months. Up to 5 months the rates at each month are higher than the Kenyan data but as pointed out the method of our data collection was different.10 At 6 months our rate is close to the 25% reported by Anyanwu, et al. [16]. Their study population was not very different from ours. In contrast Sadoh, et al. had a rate of 11% but their sample size was very small and they only included doctors [12]. On the other hand Renitha, et al. report a high figure of 58% exclusive breastfeeding rate at 6 months [15]. Their subjects were however a bit different because they included spouses of health professionals and covered a wider scope of female health professionals and the children were up to 5 years. This might have created a wider recall bias than our subjects whose children were less than 3 years. But their mean duration of exclusive breastfeeding 5.3 months was similar to our median of 5 months. Dachew in Ethiopia reported an exclusive breastfeeding rate of 35.9% among nurses and midwives [14]. Two thirds of the health workers in our study thought it was feasible to exclusively breastfeed for 6 months but a much lower percentage managed to do so. It is interesting to note that 94.2% had recommended the six month exclusive breastfeeding to others.

In this study, the intention to practice exclusive breastfeeding during the prenatal period was at 82.7%. This is similar to the study by Sadoh, et al. that showed a contrast between high intentions to breastfeed versus low rates achieved at the end of the first six months [12]. A number of studies have reviewed work and ability to continue exclusively breastfeeding let alone any breastfeeding [13, 14].

The demand of work for nurses and junior doctors in any hospital is high and unless special consideration is given most cannot breastfeed during the working period [14]. Indeed this was cited by the respondents in our study. Allocation of duty soon after resumption of work could help the female health professional to continue exclusive breastfeeding. In our study only 46% of our respondents had special consideration in allocation of duty when they resumed work. This is also cited by Weber et al. in Australia as the reason to stop breastfeeding [15]. In the USA where maternity leave is very short (about 7 weeks) resident physicians are reported to have difficulties unless very highly motivated and have support from the hospital [22, 23].

Making breastmilk available and assuring breastmilk production when mother is separated from her baby requires knowledge on breastmilk expression and storage. Only sixty percent of the respondents in our study tried to make breastmilk available. One reason for this could be a reflection of lack of knowledge since only 34% participants in the current study had had any post basic training on lactation management. Since 1992 KNH has had the WHO infant and young child feeding course but it has not been possible to cover all workers. In addition there is a rapid turnover of staff. The other reason is that KNH has not made any provision for its workers to express their breastmilk during the working period. Basrowi et al. showed a 2.7 fold increase in exclusive breastfeeding and a 5.9 fold increase in knowledge in institutions that had dedicated breastfeeding facility and support programme [21, 24].

Almost all respondents said that it was important to have a breastfeeding policy within the hospital 94.2% and mentioned provision of nursing rooms and breastmilk storage facility as the major supporting factor. This was echoed in other studies done in the US A [25, 26, 27, 28]. It is possible to avail facility for lactating women in health institutions as described by Allen et al. in the USA and Dodgson et al. in Hong Kong [29, 30]. If space is availed there are several ways that can support female workers in health institutions as explored by Weber et al. in Australia [18]. Just after this study Kenya government introduced a breastfeeding mothers’ bill that mandates all employers to provide space and facility at the work place which KNH can adopt for all its lactating women employees [31]

Success of breastfeeding also depends on support of the people around the mother. In our study three quarters of the respondents said that they were encouraged by their colleagues during breastfeeding and this closely compared with a survey done to examine the influence of encouragement on breastfeeding women [13, 17, 18].

Early initiation of breastfeeding is one way of ensuring adequate lactation. Our study shows a low initiation rate of 69.8 % just slightly higher than the national initiation rate of 62% [10]. This is close to the 74.2% reported by Dachew in Ethiopia but a lot higher than the Nigerian study [12, 14]. These rates are very dependent on hospital practices which we did not explore in the current study. Often delayed initiation is accompanied by use of prelacteal feeds. In our case this was practiced by 22% and most of these had delivered through caesarean section. A similar figure of 19% was reported by Dachew, et al. in Ethiopia [14].

A large number (81.3%) reported a decrease in breastmilk supply on return to work; a similar finding to other studies [13, 17]. The decrease was most likely due to infrequent emptying of the breasts. The decrease in breastmilk plus mother being away for the baby led to introduction of other feeds. Most respondents (35.3%) used formula milk as an alternative feed compared to 18.6% cow milk use; 10.8% gave cereals and 6.5% water. Ideally cereals and water should not have been used. Other reasons given were baby seemed hungry, and some wanted the baby to sleep long, baby old enough. All these reasons are similar to other studies and do not differ from those given by non medical mothers. Again this displays lack of knowledge among our study subjects

Conclusion

Our work shows a great disparity between intention 82% and the exclusive breastfeeding rate for the first six months of 29.2%. Initiation within an hour of birth was also low at 69.8% with those delivering by Caesarean section taking longer which lead to the use of prelacteal feeds. Return to work without an enabling environment was the most common contributing factor. Provision of facility at the work place plus adequate information to the health workers can go a long way to increase exclusive breastfeeding among female health professionals

Disclosure Statement

Authors have no competing financial interests.