Current Knowledge of Breastfeeding Among Health Workers in a Developing Country Setting: A Survey in Calabar, Nigeria

Background Health workers are in a strategic position to provide correct information to mothers on breastfeeding practice. This study assessed knowledge of breastfeeding among health workers in health facilities in Calabar. Methods This was a cross-sectional descriptive study. A 45-item self-administered questionnaire was used to obtain data. Ethical clearance for the study was obtained from the Cross River State Research and Ethics Committee. Data were analyzed using SPSS version 21.0 (SPSS, Inc., Chicago, USA). A knowledge score of at least 90% was considered satisfactory. Factors associated with the level of knowledge were determined using chi-square. The p-value was set at 0.05. Result Two hundred and twenty-five healthcare professionals were surveyed, with a mean age of 37.5 ± 9.4 years, ranging from 20 to 65 years. The commonest age group was 41 to 50 years (43.1%). Females (80.9%) formed a larger proportion of participants with a female-male ratio of 4:1. The mean percentage of knowledge score was 85.1 ± 9.0%. A satisfactory level of knowledge was found in 27.1% of respondents. About one-third (33.7%) and one-fifth (21.8%) of health workers were not aware of the weight control benefit and protection against osteoporosis of breastmilk, respectively. Approximately one-fifth (22.2%) of respondents had misconceptions concerning the effects of colostrum on the prevention of neonatal jaundice. Nurses with diploma level of training had a satisfactory level of knowledge, compared with other professions (p < 0.05). Conclusion Health workers’ knowledge of breastfeeding was generally good though suboptimal. Health-related professions should provide current information on the best breastfeeding practices.


Introduction
Breastfeeding is a public health strategy for improving infant morbidity and mortality [1]. Exclusive breastfeeding decreases the risk of mortality from diarrhea and pneumonia [2]. It supports the immune system of the infant and could protect from later life non-communicable diseases such as diabetes and obesity [2]. The World Health Organization (WHO) and United Nations Children's Fund (UNICEF) recommends that every infant be exclusively breastfed for the first six months of life, with breastfeeding continuing for up to two years of age [3]. The UNICEF 2019 global databases show that only 44% of newborns are commenced on breastmilk within one hour of delivery and about 40% of infants are exclusively breastfed in the first six months of life [2].
The exclusive breastfeeding rate for children under six months in Nigeria is 29% following the 2018 Nigeria Demographic Health Survey (NDHS) with the average duration of exclusive breastfeeding in Nigeria being 2.8 months [4]. This is the highest in Nigeria in the last decade from 2008 to 2018, where the rate was 13% in 2008 and 17% in 2013% [4,5].
There are many factors contributing to the unacceptable low rates of breastfeeding globally [6][7][8]. One of the 1 2 3 3 4 factors is the role of health workers. Health workers play a key role in supporting the initiation and establishment of effective breastfeeding of neonates by their mothers. Health workers are in a strategic position and have the responsibility to educate and counsel mothers and the general public towards proper initiation and adherence to recommended infant feeding practices [6][7][8]. Health workers are expected to have at least sufficient knowledge of various aspects of breastfeeding, including its benefits, proper techniques, existing myths, and practical aspects of managing potential challenges. Inadequate support by health workers towards positive breastfeeding practices has been reported in the past [9,10]. Okolo and Ogbonna working in Keffi, Nigeria showed that there was poor awareness of health workers in promoting and sustaining breastfeeding [11]. In a study carried out in Ikom, South-South Nigeria, about one-third of the health workers could not name more than two components of breast milk and 75.1% failed to identify more than three advantages of breastfeeding [12]. Improved healthcare practices stand out as being the most promising means of reinforcing the prevalence and duration of breastfeeding [10].
The majority of nursing mothers are largely dependent on health workers for acquisition and improvement in their knowledge of breastfeeding [12].
Health workers are an important source of support for breastfeeding mothers and their knowledge can influence a mothers' decisions to initiate and continue breastfeeding. There is a dearth study on the knowledge of healthcare professionals on breastfeeding in Cross River State hence this study. Findings from this study will be used in developing appropriate strategies to promote breastfeeding practices in Cross River State and Nigeria as a whole.

Study area
The study was conducted in Calabar, the capital city of Cross River State, in the south-south geo-political zone of Nigeria.

Study design
This was a cross-sectional study.

Study population
The study participants comprised of nurses, medical doctors, community health workers, pharmacists, and physiotherapists. Participants were attendees at a nutrition workshop in Calabar drawn from primary health centers, private hospitals, secondary health facilities, and tertiary health facilities in Calabar.

Sample size estimation
The formula for single proportion [13] n = z2pq/d2 was used to calculate sample size in this study, where n was the sample size, "z" critical value set at 95% alpha level of significance (1.96), "d" was estimated margin of error (0.05), "p" was estimated proportion of health workers with adequate knowledge of exclusive breastfeeding (0.84) as reported in the previous study [14] and q = 1-p = 0.16. With the assumption of a 5% non-response rate, this yielded a minimum sample size of 217.

Sampling technique
Attendees were recruited to participate in the workshop and the study from their different health institutions (place of practice) in Calabar, using a systematic random sampling technique, with registers obtained from the Cross River State Ministry of Health as the respective sampling frames. Each sampling interval (k) was calculated by dividing the number of relevant staff in the different institutions (using available registers) by the proportionately allocated sample size for that institution. Hence, sampling intervals k of 5, 3, 3, 4, 2 was estimated for tertiary (622/122), general (57/19), private (127/39) hospitals, and primary health care (86/23) and other (47/22) centers, respectively. Subjects were recruited by balloting between the first participant and the kth participant on the respective registers. Thereafter, subsequent subjects were recruited using the estimated sampling interval for the different institutions. If a subject did not consent to participate, the next staff on the register was selected and sampling continued from that point. Sampling was carried out until the estimated sample size was completed.

Data collection
A 45-item self-administered semi-structured questionnaire assessing different aspects of breastfeeding was used to obtain data from consenting participants. The questionnaire consisted of demographic data of the participants and breastfeeding knowledge: benefits to babies, benefits to mothers, colostrum, effective feeding, timing and duration of breastfeeding and complementary feeding, common breastfeeding problems, and practical aspects of breastfeeding. Ethical clearance for the study was obtained from the Cross River State Research and Ethics Committee. The confidentiality of the participants was preserved by the use of identification numbers

Statistical analysis
Data were analyzed using Statistical Package for Social Sciences (SPSS version 21.0, Chicago, Inc., USA). The participant's characteristics were described using frequency and percentage for categorical variables and means for continuous variables. The sum of correct responses was determined for each respondent. A knowledge score of ≥ 90% was classified as Good, 50-89% classified as Fair while < 50% was classified as Poor.
The knowledge score was further classified as satisfactory if ≥90% or unsatisfactory if <90%. Pearson's chisquare test was used to determine the association between the socio-demographic variables of the participants and their knowledge of breastfeeding. The test was deemed significant at p-value < 0.05.

Socio-demographics of participants
Two hundred and twenty-five healthcare professionals including medical doctors, nurses, community health workers, and others were surveyed, with a mean age of 37.5 ± 9.4 years, ranging from 20 to 65 years. The commonest age group was 41 to 50 years (43.1%). Most subjects were females (80.9%), married (59.6%), nurses (60.0%), practiced in a tertiary hospital (54.2%), and have had 10 or less years of practice experience (57.8%; Table 1).

Overall knowledge score of participants on breastfeeding practice
The mean score on knowledge of breastfeeding was 40.0 ± 4.2, ranging from 13.0% to 45.0%. This corresponded to mean percentage score of 85.1 ± 9.0%, ranging from 27.7% to 100%.

Discussion
The overall knowledge of health workers on breastfeeding practices in this study was 85.1 ± 9.0% which was below the cut-off of 90.0% for satisfactory knowledge. Satisfactory knowledge of breastfeeding practices was observed in 27.1% of the respondent. This is, however, lower than that observed by Utoo et al. working in the sub-urban city of Ikom [12]. The paucity of knowledge on breastfeeding practices among health workers in the index study raises concerns about the quality of health talks and counselling offered to mothers and other caregivers of young infants in health facilities.
Knowledge of health workers on the benefits of breastfeeding to babies, their mothers, colostrum, effective breastfeeding, timing, and duration of exclusive breastfeeding and complementary feeding was good. However, their knowledge was suboptimal regarding the effect of breastfeeding on the achievement of prepregnancy weight, protection against osteoporosis, and colostrum in the protection of babies from jaundice. In a survey conducted in Tanzania, 97% of health workers stated a lack of knowledge of the benefits of exclusive breastfeeding as one of the main reasons for the low breastfeeding rate [15]. A majority of the general public including nursing mothers largely depend on health workers for acquisition and improvement of their knowledge of breastfeeding [12].
Most of the respondents had satisfactory knowledge of the importance of colostrum. This is like that observed by Utoo et al., colostrum is known to have several immunologic properties that protect the baby against infections in early life [12]. Mothers are more likely to practice exclusive breastfeeding if they know the protective function of colostrum against several pathogenic gut organisms. However, 77.8% of health workers had poor knowledge about colostrum protecting babies from jaundice. This level of knowledge is highly unacceptable as jaundice is among the leading causes of neonatal morbidity and mortality in most developing countries [16].
About 96% of health workers knew that breastfeeding should be initiated within one hour after delivery. This finding suggests that women attended by these health workers were more likely to commence breastfeeding of their infant soon after delivery. This finding is similar to that obtained in a study among health workers in rural South Africa, which reported a knowledge rate of 96% among professional nurses [10], however, the study in Keffi, Nigeria reported a lower knowledge rate of 20% of initiation of breastfeeding within one hour after delivery [11].
Most of the respondents knew exclusive breastfeeding to be recommended for the first six months of life. This finding is similar to that obtained in Ikom, Nigeria among health workers [12]. This response of health workers if sustained and practiced by nursing mothers could improve the low exclusive breastfeeding rate in Nigeria.
Although, 12.4% of health workers believed that infants less than six months should be given water during exclusive breastfeeding. This is however lower than 19.2% and 15.7% that subscribed to the use of water alongside breastfeeding before six months of life by Okolo and Ogbonna [11] in Keffi, Nigeria and Sadoh et al. [17] among medical women in Benin City, Nigeria, respectively. This response by health workers may reflect the common cultural myth in Nigeria that breastfed babies are usually thirsty and would need to drink some water in order to be satisfied. Sachdev et al. [18] had demonstrated that fully breastfed babies in the tropics do not need water even in extremely hot dry climates.
Knowledge concerning common breastfeeding problems was generally not satisfactory. Good knowledge was reported in 10% of the questions used to assess the participants in this domain. About a quarter of the respondents believed that breastfeeding should be discontinued if mothers have cracked nipples or breast engorgement while about half of them believed mothers with inverted nipples cannot breastfeed their babies. The above-mentioned problems for which the health workers permitted discontinuation of breastfeeding are remediable challenges that should not obviate the practice of breastfeeding. Reasons similar to the findings in this study were attributed to the premature discontinuation of breastfeeding in Keffi, Nigeria [11] and by Chale et al. [15] in Tanzania, East Africa. This may suggest that health workers in these settings will not promote breastfeeding among mothers with those conditions. Borbala [6] and Robertson [8] have shown that poor knowledge of breastfeeding among health workers impair effective breastfeeding practices.
The age of the health workers, gender, and years of practice were not significantly associated with satisfactory knowledge of breastfeeding in this study. Chale et al. in Tanzania [15] demonstrated that years of practice, age, and gender were not significantly associated with good knowledge of breastfeeding among health workers.
There was a significant association between the cadre of health staff and knowledge of breastfeeding in this study. The knowledge of breastfeeding practice was significantly higher among those with a diploma in nursing compared with other health professionals. Medical doctors had inadequate knowledge of breastfeeding compared to nurses. The observation in this study is quite understandable since most of the health education to caregivers in health facilities is performed by nurses. The finding in this study is however contrary to the report of Chale et al. [15] and Okolo and Ogbonna [11] who reported better knowledge of breastfeeding practices among medical doctors and a higher likelihood of clinicians encouraging the practice of exclusive breastfeeding compared to other health workers.
A limitation of this study is the skewness in favour of nurses in the selection of participants This bias in the selection of respondents might have influenced some of the findings of this study, though most of the respondents were from the tertiary health facility with a representative from more than ten states of Nigeria and the neighbouring Republic of Cameroun.

Conclusions
The overall knowledge of health workers on breastfeeding practices was suboptimal. Health workers had good knowledge of the benefits of breastfeeding and breastfeeding practices but their knowledge of common problems of breastfeeding and practical steps on breastfeeding was quite low. Training and re-training of all health workers in the State on the importance of breastfeeding are necessary to improve their knowledge of breastfeeding practice.