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Table of Contents
Year : 2022  |  Volume : 27  |  Issue : 2  |  Page : 137-142

World Health Organization’s recommendation on breastfeeding: Knowledge and practices of nursing mothers in Enugu, Nigeria

1 Department of Paediatrics, Enugu State Teaching Hospital Parklane, Enugu, Nigeria
2 Department of Paediatrics, College of Medicine, University of Nigeria Ituku-Ozalla, Enugu, Nigeria

Date of Submission08-Jun-2021
Date of Decision29-Jun-2021
Date of Acceptance01-Sep-2021
Date of Web Publication3-Mar-2022

Correspondence Address:
Adaobi I Bisi-Onyemaechi
Department of Paediatrics, College of Medicine, University of Nigeria Ituku-Ozalla, Enugu.
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijmh.IJMH_25_21

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Background: The World Health Organization (WHO) has made recommendations for breastfeeding. These recommendations are to promote proper breastfeeding practices, which are essential for improved child health and survival. Objectives: The study intended to determine the level of awareness of WHO breastfeeding recommendations among nursing mothers in Enugu and how awareness translates into practice. Materials and Methods: A questionnaire was used to assess the awareness of WHO recommendations on breastfeeding and breastfeeding practices of mothers in Enugu, Nigeria. Results: Most (254; 64.1%) mothers have not heard about the WHO recommendation on breastfeeding; majority (81.1%) were aware of exclusive breastfeeding. Antenatal clinics are the commonest source of information on breastfeeding. Only 2.5% mothers intend to breastfeed for the duration recommended. Awareness of WHO recommendations was not associated with decision to breastfeed or frequency of breastfeeding. Younger mothers were less likely to be aware of the recommendation (P = 0.007, OR = 0.559, 95% CI = 0.366–0.851), while antenatal care attendance was associated with increased awareness (P = 0.002, OR = 10.389, 95% CI = 2.439–44.262). Maternal education affected breastfeeding frequency only. Conclusion: Significant gaps exist in awareness of the WHO recommendations on breastfeeding among mothers in Enugu, Nigeria.

Keywords: Breastfeeding, Enugu, recommendations, WHO

How to cite this article:
Nduagubam OC, Bisi-Onyemaechi AI, Ndu IK, Onukwuli VO, Amadi O, Ogbuka FF, Ezenwosu O, Iheji C. World Health Organization’s recommendation on breastfeeding: Knowledge and practices of nursing mothers in Enugu, Nigeria. Int J Med Health Dev 2022;27:137-42

How to cite this URL:
Nduagubam OC, Bisi-Onyemaechi AI, Ndu IK, Onukwuli VO, Amadi O, Ogbuka FF, Ezenwosu O, Iheji C. World Health Organization’s recommendation on breastfeeding: Knowledge and practices of nursing mothers in Enugu, Nigeria. Int J Med Health Dev [serial online] 2022 [cited 2022 Dec 7];27:137-42. Available from: https://www.ijmhdev.com/text.asp?2022/27/2/137/339030

  Introduction Top

Breastfeeding no doubt remains the best way of providing ideal food for the newborn child. It is critical in child health and survival and should be a significant component of child health promotion. The promotion of adequate breastfeeding can, therefore, reduce child mortality.[1] It was in line with this fact that the World Health Organization in 2001 recommended exclusive breastfeeding (EBF) in the first 6 months of life and breastfeeding along with safe and nutritionally adequate complementary food till the child is at least 24 months of age.

Although the benefits of breastfeeding are widely known and documented[1],[2],[3],[4] and recommendations for it made by World Health Organization (WHO) in 2001,[2] only a small percentage of infants in developing countries are exclusively breastfed, and even a fewer percentage were continued on breastfeeds for at least 24 months.[5],[6] Previous studies on breastfeeding awareness have concentrated on the health benefits of breastfeeding and infant feeding practices.[7],[8],[9] Although some studies have suggested that improving the understanding and comprehension of mothers on breastfeeding recommendations should be central in efforts to encourage mothers to breastfeed their children, only a few studies have looked into whether mothers actually understand the recommendations and what the recommendations mean to them.[10],[11] The decision to breastfeed is dependent on many factors, including knowledge, attitudes, and beliefs, as well as sociocultural and emotional factors.[6],[7],[8],[12],[13],[14],[15] For example, an average breastfeeding mother sees pregnancy as a condition to stop breastfeeding the baby, else the baby may die; some are of the opinion that once they have not breastfed a baby for some days due to one challenge or the other, their breast milk rather becomes stale and unsafe for the baby. In addition, some mothers have been made to believe that their breast milk is bad. Furthermore, a study in Greece found that maternal intention to breastfeed was influenced by maternity leave provision, maternal age, paternal education, the region of upbringing, and season of delivery.[16]

Very few studies have looked at the impact of awareness of the WHO breastfeeding recommendations in mothers’ decision to breastfeed. Therefore, the role of these recommendations in improving the adoption and practice of breastfeeding is still unknown.[17]

Of the few studies so far that have evaluated mothers’ awareness of the WHO recommendation, none was done in Nigeria despite its low EBF rate. Although awareness has been observed to be independently associated with the intention to meet these recommendations,[10],[11] there is a need to examine whether their level of awareness is in keeping with their actual breastfeeding practices. This study, therefore, assessed the awareness of breastfeeding mothers attending the well child clinics at the two tertiary hospitals in Enugu South East Nigeria about the WHO recommendations on breastfeeding and the relationships between their awareness of the WHO recommendation on breastfeeding (from birth to at least 2 years) and their actual practice.

  Materials and Methods Top

Ethics approval

Ethical approval was obtained from the Health Research Ethics Committee of the Enugu State University Teaching Hospital ESUTH/ Parklane, Enugu Nigeria. Written informed consent was obtained from all participants.

Study design

This was a descriptive, cross-sectional hospital-based study.

Study area/site

The study was carried out in the well child clinic of two hospitals: Enugu State University Teaching Hospital ESUTH and Parklane and University of Nigeria Teaching Hospital UNTH, both in Enugu state, South East Nigeria. These two facilities offer primary, secondary, and tertiary healthcare services to persons of all social classes and are referral centers for the population of Enugu State and its environs.

Study population

The study population comprised breastfeeding mothers who attended the well child clinic of ESUTH and UNTH and who met the inclusion criteria. Mothers who gave consent for the study were recruited consecutively over a 6-month period (September 2018 to February 2019). The well child clinics of these two facilities are held twice a week from 8 AM to 4 PM and attend to an average of 50 mother/child pairs per day. A total of 396 breastfeeding mothers were recruited from September 2018 to February 2019.

Exclusion criterion were mothers who were no longer breastfeeding and who did not give consent.

A structured questionnaire was administered. The questionnaire contained baseline sociodemographic information; questions to assess awareness/understanding of the WHO recommendation on breastfeeding; the breastfeeding practices (EBF and continuation of breastfeed along with appropriate complementary feeds till the child is atleast 24 months) mothers practiced in their previous children and their intention to meet the recommendation with the current baby.

Statistical analysis

Data obtained were transferred into the data editor of Statistical Package for Social Sciences software for Windows, version 22. Descriptive statistics such as mean (±SD) and median were obtained for continuous variables while categorical variables were summarized using frequencies and percentages. The χ2 test of significance was applied to establish their association with awareness of recommendation and breastfeeding practice. The level of significance was taken as P < 0.05. Results are presented in tables.

  Results Top

Most (210; 53%) of the mothers in this study were within the age group of 20–30 years. Only 2.8% of mothers were <20 years of age. Majority (372; 93.9%) were married, and 219 (55.3%) of them had two or more children. Most (265; 66.9%) of the mothers were working/employed, and 92.7% (367) had at least primary education. Almost all the mothers had no known breast condition or disease, and most attended antenatal care during pregnancy [Table 1]. A total of 346 (87.4%) participants had children <6 months of age.
Table 1: Mother’s characteristics

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Mothers’ awareness of breastfeeding

Majority (254; 64.1%) of the mothers have not heard about the WHO recommendation on breastfeeding, although a large number of mothers (273; 68.9%) knew that breastfeeding should be commenced within 1 hour of delivery; most (321; 81.1%) of the mothers had heard about exclusive breast feeding with antenatal clinics (247; 76.9%) being the most common source of information about EBF. Most of the study participants who had heard about exclusive breastfeeding were able to describe its components, i.e., breast milk only (91%) and the duration (98.1%). Majority (247; 76.9%) agree that exclusive breast feeding is beneficial to the babies. The most common reasons given were that it makes the baby healthy and prevents illnesses (161; 65.2%) and that it was helpful for the baby’s brain development (57; 23.1%).

Among those who have heard about exclusive breast feeding, most (171; 53.3%) are of the opinion that breast feeding is not beneficial to the mother. Among those who said it was beneficial to the mother (150; 46.7%), the major reasons given were the role of breastfeeding in reducing risk of breast cancer (42; 28%), reducing the cost of infant feeding (25; 16.7%), and that it helps uterine involution (17; 11.3%).

Mothers’ attitude to breastfeeding

Among the 396 mothers studied, 260 (65.7%) said they intend to stop breastfeeding their index baby by the time they are aged 12 months while 119 (30.1%) intend to continue breastfeeding up to the age of 18 months. Only 10 (2.5%) mothers intend to breastfeed in accordance with the WHO recommendation for at least 24 months.

A total of 205 (59.2%) out of the 346 mothers who have children who are aged <6 months were giving their children other food items, which is against the WHO recommendation that stipulates giving a child only breast milk till 6 months of age. The items given along with breast milk are water (54.1%), artificial milk (40%), and local cereals (corn gruel/pap [5.9%]). One hundred and fifty-four (88.8%) did not offer any reason for their action. Of the 51 mothers who gave reasons, the most common reasons were their involvement with the work/employment (19.6%), twin delivery (15.7%), and birth through caesarean section (5.9%).

Mothers’ breastfeeding practices

Majority (389; 98.2%) of the mothers breastfeed, and most (346; 87.4%) breastfeed their children at least eight times in 24 hours. Among the 321 mothers who had heard about exclusive breastfeeding, only 131 (40.8%) practice EBF while 281 (89.5%) breastfeed their children eight or more times in a day. [Table 2] shows that the awareness of all the WHO recommendations on breastfeeding was not significantly associated with mothers’ decision to breastfeed (P = 0.256), neither was it significantly associated with the number of times they breast fed their children in a day (χ2 = 0.348; P = 0.555).
Table 2: Relationship between the awareness of WHO recommendation on breastfeeding and factors of breastfeeding and frequency of breastfeeding per day

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Mothers aged 20–30 years of age were less likely to be aware of the WHO recommendations than those >30 years of age (P = 0.007, OR = 0.559, 95% CI = 0.366–0.851). Mothers who attended antenatal care were 10 times more likely to be aware of the WHO recommendations than those who did not (P = 0.002, OR = 10.389, 95% CI = 2.439–44.262).

Mothers’ awareness of EBF was not associated with their decision to breastfeed (P = 0.356) [Table 3], neither was it associated with how many times their children breastfeed in a day (χ2 = 0.491; P = 0.483).
Table 3: Relationship between mother’s awareness of exclusive breastfeeding and their practice of breastfeeding and the frequency of breastfeeding in a day

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Study participants ≤30 years of age were less likely to be aware of exclusive breastfeeding than those >30 years of age (P < 0.001) [Table 4].
Table 4: Relationship between mothers’ characteristics and their awareness of exclusive breastfeeding

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Mothers with higher level of education were more likely to be aware (χ2 = 21.917, P < 0.001) [Table 5]. Mothers who attended antenatal care were 24 times more likely to be aware of exclusive breastfeeding than those who did not (P < 0.001, OR = 24.689, 95% CI = 10.432–58.431). Maternal level of education (χ2 = 9.056, P = 0.011) but not age or attendance to ANC was significantly associated with mothers’ practice of breastfeeding their children at least eight times in a day. Mothers who had primary education and above were more likely to breastfeed their children atleast eight times in a day compared with mothers who had no formal education [Table 4].
Table 5: Association between maternal characteristics and awareness of WHO recommendation on breastfeeding

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  Discussion Top

Studies[18],[19],[20] have continued to report a high awareness of EBF; thus inclusive (81%) and antenatal clinics have remained the commonest source of information on breastfeeding for mothers similar to the finding in this study.[18],[19],[20] There is, therefore, a need to strengthen access to prenatal care and its capacity to provide comprehensive health education and information especially on breastfeeding. This should include its benefits to the mother, family, and community at large, as the participants in this study (53%) didn’t think EBF was beneficial to mothers. A report[21] from China stated that 22% of mothers did not think breastfeeding was beneficial to mothers. Although the study participants were not aware of the “WHO Recommendation label,” most were aware of the different components of it, e.g., initiation of breastfeeding (68.9%), duration of breastfeeding (79.4%), etc. This is not unexpected as the health workers would likely emphasize the contents of the recommendation during the limited time available for health talks in the clinics rather than the source. It was also noted that awareness of EBF did not determine the practice of breastfeeding, duration inclusive unlike a previous finding in Chinese mothers.[21]

EBF rate among the study participants was just about 40%, which is discordant with their awareness of the practice (81%) and its benefits (65%). EBF rate in this study is a slight improvement to previously documented studies in this clime.[18],[19],[22],[23] The nonhuman milk feeds given to these babies are similar to what has been previously reported also.[18],[22],[23],[24] Majority did not have any reason for this practice, and this suggests the need to adopt EBF with convincing and sustained information, education, and communication on the benefits of EBF.

Intension to breastfeed up to 24 months and beyond as recommended by WHO was very low (2.5%) among the mothers who participated in the study unlike a study by Muelbert and Giugliani[25] that reported a breastfeeding rate of 31% at 24 months among adolescent mothers in southern Brazil. The low rate of intension to breastfeed up to 24 months may be because the interpregnancy intervals (IPI) in this environment are usually <24 months and can be as low as 11.1 months in younger mothers as documented in Enugu.[23],[25],[26] This short IPI is associated with a cultural disruption of breastfeeding for the index infant on the belief that breastfeeding is contraindicated in pregnancy.[27],[28],[29] This recommendation affords the mother time to recover from the stress of pregnancy, nurture the index baby, and promote child spacing in some women.

Awareness of the WHO recommendation on EBF, frequency, and duration of breastfeeding was not associated with practice as found in this study. Breastfeeding practices in Sub-Saharan Africa have rather been shown in some studies to be affected more by significant others in the family and culture,[18] although this study did not study the effect of significant other on breastfeeding practices. It, however, observed a positive effect of educational status on breastfeeding frequency.

Younger mothers were less aware of the WHO recommendations because they are more likely to have had fewer pregnancies with fewer visits to antenatal clinics (when compared with the older ones), which was shown to be the primary source of health-related information for women of child-bearing age.[18],[30]

  Conclusion Top

Mothers in this study knew to varying degrees the different components of EBF although awareness of these recommendations has not resulted in its adoption. Mothers who attend ANC are 10 times more likely to be aware of the WHO recommendation on breastfeeding.


It is recommended that the capacity of antenatal clinics should be strengthened to deliver sustained adequate and correct information on breastfeeding according to WHO recommendations. Efforts should be targeted to ensure mothers translate their knowledge/awareness of this recommendation into practice.

Further studies are required on the reasons why mothers despite being aware of EBF (81% in this study) do not practice it (40%).



Paper context

WHO made recommendations on breastfeeding. Its adoption is critical in Sub-Saharan Africa as breast feeding is a key component of child survival strategies. The usefulness of these recommendations in improving child health statistics in Africa lies in its understanding and adoption. This study investigated mothers’ knowledge about these recommendations, the extent of its adoption, and factors that determined these. Gaps in knowledge and practice can be subsequently improved based on evidence.

Financial support and sponsorship

The authors have no financial relationship relevant to this article to disclose. This research did not receive any grant from funding agencies in the public, commercial, or not-for-profit sectors.

Conflicts of interest

There are no conflicts of interest.

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  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]


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