- Email: [email protected]
Mothers’ knowledge and intentions of breastfeeding in Marrakech, Morocco
Archives de Pe´diatrie 26 (2019) 285–289
Available online at
ScienceDirect www.sciencedirect.com
Research paper
Mothers’ knowledge and intentions of breastfeeding in Marrakech, Morocco E. Jasny *, H. Amor, A. Baali Laboratory of Human Ecology, Faculty of Science Semlalia, Cadi Ayyad Marrakesh University, Prince Moulay-Abdellah street, 2390, Marrakesh, Morocco
A R T I C L E I N F O
A B S T R A C T
Article history: Received 23 May 2018 Received in revised form 12 March 2019 Accepted 22 May 2019 Available online 3 July 2019
Exclusive breastfeeding immediately after birth and during the first 6 months of life is the best source of nutrition for an infant. Its well-documented benefits are countless. Several studies highlight the relation between women’s knowledge of breastfeeding, their attitudes, and their subsequent behavior. In this perspective, we conducted a study to examine the intentions and prenatal knowledge of mothers on breastfeeding. In a survey conducted from September 2013 to June 2015, 768 women were interviewed in different maternity units in Marrakech and its surrounding rural area. The mothers’ mean age was 27.6 years, 30.1% of them were illiterate, and 48.2% were from rural areas. A total of 95.3% of the mothers received information concerning breastfeeding during pregnancy. The immediate circle of family and friends was the main source of information (52.8%), while healthcare professionals accounted for only 14%. Of the women surveyed, 57.5% had the intention during pregnancy to breastfeed their babies, and 81% wished to breastfeed for more than 12 months. The level of knowledge was related to the mother’s age, education level, and parity. It should be noted that as their age increases women tend to choose breastfeeding exclusively for long periods. The level of knowledge and intentions of mothers regarding breastfeeding are associated with the success of this practice; however, the rate of breastfeeding continues to decline both nationally and regionally. Therefore, several measures should be taken to promote breastfeeding.
C 2019 French Society of Pediatrics. Published by Elsevier Masson SAS. All rights reserved.
Keywords: Breastfeeding Knowledge Intentions Breastfeeding benefits Breastfeeding duration
1. Background Breastfeeding is the reference for infant feeding during the first months of life. It promotes the child’s physical and psychological development, privileges mother–child bonding, and strengthens immunity [1]. Many studies have indicated that breastfeeding improves children’s health, including lower rates of childhood infections and malocclusion, higher intelligence quotient scores, and lower rates of obesity and diabetes [2,3]. Recommendations agree that ideally, children should benefit from exclusive breastfeeding during the first 6 months or at least that weaning should not occur until 4–6 months [4]. The practice of breastfeeding is currently declining throughout the world. In France, the Abbreviations: CI, confidence intervals; SD, standard deviation; Lv, level of knowledge; OR, odds ratio; SPC, socioprofessional category; WHO, World Health Organization. * Corresponding author. E-mail address: [email protected] (E. Jasny).
E´pifane study reports that at 3 months, one infant out of three is breastfed and only 10% benefit from exclusive breastfeeding [5]. In Tunisia 9% of infants less than 6 months are exclusively breastfed, this same rate reached 27% in Lebanon in 2016 [6]. Morocco does not escape this phenomenon: breastfeeding has also been the subject of a worrying decline. In 1992, 51% of children were breastfed during the first 6 months of life, whereas this frequency was only 31% and 27.8% in 2004 and 2011, respectively [7,8]. At the regional level, the city of Marrakech is not an exception: according to the national survey on population and family health, the rate of exclusive breastfeeding is only 29% [8]. The factors that influence the practice of breastfeeding are numerous and complex, related for example to the mother herself (age, level of education, occupational activity, etc.) with her intentions and knowledge on breastfeeding [9], as well as her baby and its health status [10]. Moreover, several studies have underscored the link between women’s knowledge on breastfeeding, their attitude toward this way of feeding, and their subsequent behavior. Several studies have reported that women who had a
https://doi.org/10.1016/j.arcped.2019.05.007 C 2019 French Society of Pediatrics. Published by Elsevier Masson SAS. All rights reserved. 0929-693X/
286
E. Jasny et al. / Archives de Pe´diatrie 26 (2019) 285–289
positive attitude towards breastfeeding had extended length of exclusive breastfeeding time [11]. Indeed, women who know the benefits of breastfeeding would be more likely to choose it [12]. It has also been shown that the prenatal intention to breastfeed over a prolonged period is significantly associated with prolonged breastfeeding. The stronger the mother’s intention to breastfeed during the prenatal period, the more likely she is to breastfeed exclusively after the baby is born [13]. In addition, the objectives of the present study were to assess the knowledge and intentions towards the breastfeeding of a group of Moroccan postpartum mothers in the province of Marrakesh and to understand the socioeconomic, demographic, and healthrelated factors.
2. Subjects and methods 2.1. Study design This is a prospective and analytic cross-sectional survey. Our sample included a total of 768 women aged 17–46 years. The survey was conducted after obtaining permission from the Moroccan Ministry of Health and the Marrakech health authorities. All women provided oral consent before participating in the survey. We used a very detailed questionnaire, which was validated by the Marrakech health authorities and tested previously. The information was collected anonymously and confidentially. After their oral consent, women were interviewed during their postpartum stay in public maternity wards in Marrakech and its rural area, after delivery, between the 1st and 2nd postpartum day. The confidentiality of the data was respected. The questionnaire, which was the basis of the interview, contains items on the sociodemographic profile of the women interviewed (age, urban/rural origin, education level, parity) and several characteristics related to pregnancy and childbirth (follow-up and where the pregnancy was followed up, term, and mode of delivery). Women’s knowledge and attitudes towards breastfeeding were assessed through two questions: the first question concerns the benefits of breastfeeding. The women’s responses to this question were grouped into six main groups: infant health (protection against diarrhea infections, prevention of allergies, enhanced immunity, normal development during the 1st months of life), maternal health (protection against breast cancer and hemorrhage, uterine involution, loss of weight gained during pregnancy, contraceptive means), complete food (contains all necessary nutrients for the baby), accessible food (no preparation, adequate temperature, etc.), normal psychoaffective development of the infant (strengthening mother–child relationship, affection, etc.), and the economic advantages for the family. The level of women’s knowledge was established from the number of benefits mentioned. Thus, the women were classified into two groups: group 1 with an unsatisfactory level of knowledge (Lv1), including all women mentioning only one benefit, and group 2 with a medium to the satisfactory level of knowledge (Lv2), where women knew at least two advantages. The second question is related to the planned duration of breastfeeding the child: duration of breastfeeding less than 12 months and duration of breastfeeding more than or equal to 12 months. 2.2. Data analysis A descriptive analysis was performed using means and standard deviations (SD). To estimate the significance of the differences observed between the means, the Chi2 test was used for categorical variables.
Multivariate analysis was used to identify each factor independently associated with the level of women’s knowledge and with the desired breastfeeding duration. Associations were measured in odds ratios (OR) with 95% confidence intervals (95% CI). The statistical significance was set at P < 0.05. The statistical treatment of data was performed using SPSS software PC-FR, version 10. 3. Results 3.1. Sociodemographic characteristics of the sample studied The age of the women in the sample varied from 17 to 46 years, for a mean 27.6 years (SD, 6.27 years). The sample mostly comprised mothers less than 35 years old: 82.8% (36.5% less than 25 years old and 46.4% between 25 and 34 years of age). A total of 51.8% of the parturients were from urban areas and 48.2% from rural areas. The illiteracy rate among the women studied was 30.1% (n = 231). Among the literate women (n = 537), 33.9% had a primary school education level, 36.1% a secondary school and above education level. The illiteracy rate among spouses was 27.5%. Employment was very low since 93.4% (n = 717) of the women interviewed were jobless. The 6.6% remaining were employees (4.2%) and civil servants or senior managers (2.4%). Unlike women, the vast majority of spouses, 98.4%, were involved in professional activities. Among these spouses, 19% belonged to the socioprofessional category (SPC2) made up of civil servants and professionals, while the category consisting of day laborers, workers, personal service, employees, artisans, and small traders (SPC1) comprised the majority in our sample (81%). 3.2. Health characteristics Parity, estimated by the number of children per woman (including the newborn) varied from 1 to 7, with an average of 2.25 (SD, 1.2). The primiparous women accounted for 32.6% (n = 250) of the sample, while multiparous mothers accounted for 67.4% (n = 518). Among the women surveyed, 89.2% (n = 685) consulted at least once during pregnancy. Also, the number of prenatal visits varied from one to ten visits, for a mean four visits (4.2 1.74). Among these women (n = 688), 32.7% benefited from one to three prenatal visits and 57.4% more than three visits. In this sample, 54.3% of women had their pregnancies followed in a private structure, 26.4% in a public structure, and 19.3% in both structures. As for delivery, 80.7% of women delivered vaginally and 94.5% of babies were full term. 3.3. Women’s knowledge of the benefits of breastfeeding The number of breastfeeding benefits mentioned by women varied from one to five (mean, 1.96, SD, 0.93). Among the women surveyed, 4.7% knew no benefits of breast milk and 25% knew one advantage (n = 192), 46.2% two benefits (n = 355), and 24.1%, three benefits and more (n = 185). Among the benefits reported by women, breast milk’s superiority for better health of the baby came first (42.66%), followed by better maternal health (24.42%), the best food for normal psychoaffective development of infants (12.18%), a complete food (11.03%), an accessible food (7.26%), and economic advantages for the family (2.42%). The immediate environment (family, friends) was the main source of information for the women interviewed: 52.8%. Media are also an important source of information for 37.5% of mothers. Information received from healthcare professionals and acquired from previous experience of breastfeeding accounted for 14% and 10.3%, respectively.
E. Jasny et al. / Archives de Pe´diatrie 26 (2019) 285–289 Table 1 Medium to satisfactory level of women’s knowledge and sociodemographic and health characteristics. Variables
Modalities
Women’s age
< 25 280 25–34 356 35 132 Urban 398 Rural 370 Illiterate 231 Primary 260 Secondary and more 277 Illiterate 211 Primary 222 Secondary and more 313 SPC1 617 SPC2 145 Primiparous 250 Multiparous 518 None 76 1–3 visits 251 4 visits 441
Place of residence Education level
Education level of the spouse
SPC of the spouse Parity Number of prenatal visits
Number
Lv2
x2 test
60.7 75.0 78.0 72.4 68.1 59.7 66.2 83.0 67.8 68.5 75.7 69.4 75.9 54.0 78.2 63.2 69.7 71.9
19.87a
1.66 ns 35.99a
5.14 ns
2.38 ns 47.25a 2.8 ns
ns: not significant; SPC: socioprofessional category; Lv2: a medium to satisfactory level of knowledge; SPC1: socioprofessional category consisting of day laborers, workers, personal service, employees, artisans and small traders; SPC2: socioprofessional category made up of civil servants and professionals. a P < 0.001.
The relation between the level of the women’s knowledge on breastfeeding benefits and sociodemographic and health characteristics is given in (Table 1). The level of women’s knowledge was established from the number of benefits mentioned. It appears that only parity, the woman’s education level, and then her age were statistically linked to her level of knowledge. To summarize the determining factors of the level of knowledge of the women studied, we carried out a binary logistic regression analysis (Table 2). The dependent variable corresponds to two levels of women’s knowledge on the benefits of breast milk (unsatisfactory and medium to satisfactory). The independent variables are related to the sociodemographic and health variables discussed above. The results of this analysis confirm those of the bivariate analysis (Table 1). Indeed, only the women’s education level, parity, and age variables appear to be positively associated with women’s knowledge on breast milk benefits. 3.4. Women’s intentions regarding breastfeeding The question related to the desired mode of breastfeeding was answered as follows: 57.5% said that they would adopt exclusive breastfeeding and 34.4% mixed feeding; the remaining 8.1% were undecided.
Table 2 Binary logistic regression model adjusted from medium to high knowledge level of mothers. Variables Women’s age Place of residence Education level Education level of the spouse SPC of the spouse Parity Number of prenatal visits
A 0.451 0.115 0.818 0.036 0.003 1.223 0.087
x2 10.443 0.360 37.558b 0.086 0 38.949b 0.420
1.569 1.122 2.266 1.037 1.003 3.399 1.091
(1.194; (0.770; (1.744; (0.815; (0.603; (2.314; (0.838;
3.5. Desired breastfeeding duration Of the women studied, 81% wanted to breastfeed their babies for more than 12 months, 6% for less than 12 months, and 13% were indecisive at the time of the survey. The study of the associations between the targeted duration of breastfeeding and the sociodemographic and health variables shows that only the women’s parity, their level of knowledge about the benefits of breast milk, and the mode of breastfeeding desired were significantly related to the duration of breastfeeding (Table 3). Indeed, women with a moderate to satisfactory level, multiparous women, and women who had chosen an exclusive breastfeeding mode wished to breastfeed for a period of 12 months or more. In a binary logistic regression model, the dependent variable was the duration of breastfeeding desired. The independent variables were sociodemographic and health variables studied above. This shows that the breastfeeding mode chosen, the mother’s level of knowledge, place of residence, and education level are independently linked to the desired duration of breastfeeding (Table 4). 4. Discussion The assessment of prenatal knowledge and the intentions of women regarding breastfeeding in our study affected 768 women who gave birth in various maternity units in the province of Marrakech. The sample consists for the most part of young women aged less than 35 years (82.8%). The illiteracy rate in this study was 30.1%, which is lower than in the Marrakech-Safi region in 2014 (42.1%). [14] The average number of children per woman was 2.2, very close to that recorded at the regional level in the same period (2.5%) [14]. Important for a healthy pregnancy, follow-up provides an opportunity to prepare the future mother for breastfeeding. In this study, 89.1% of women reported having had the pregnancy followed. Among these pregnancies, 57.4% had an adequate number of prenatal visits, which corresponded to more than four visits [14]. WHO has established the follow-up timing as at least Table 3 Desired breastfeeding duration and sociodemographic and health characteristics of women. Variables
Modalities
N
12
x2 test
Women’s age
< 25 25–34 35 Urban Rural Illiterate Primary Secondary and more Illiterate Primary Secondary and more SPC1 SPC2 Primiparous Multiparous None 1–3 visits 4 visits Unsatisfactory (Lv1) Medium to satisfactory (Lv2) Exclusive breast Mixed
237 314 115 342 324 202 226 238 189 190 271 540 124 200 466 66 223 377 176 490 404 215
91.6 93.9 93.9 94.2 92.0 94.6 94.7 90.3 92.6 95.8 91.5 93.0 94.4 90.0 94.4 95.5 92.8 92.8 88.1 94.9 97 87
1.3 ns
Place of residence Education level
Education level of the spouse SPC of the spouse Parity
OR (95% CI) a
2.062) 1.634) 2.944) 1.319) 1.670) 4.990) 1.419)
A: constant; x2: Wald; OR: odds ratio; CI: confidence interval; SPC: socioprofessional category. a P < 0.01. b P < 0.001.
287
Number of prenatal visits Knowledge level Breastfeeding mode
1.22 ns 4.38 ns
3.26 ns
0.3 ns 4.25a 0.63 ns
9.39a 26.46b
ns: not significant; 12: duration of breastfeeding equal to or greater than 12 months; SPC: socioprofessional category. a P < 0.01. b P < 0.001.
E. Jasny et al. / Archives de Pe´diatrie 26 (2019) 285–289
288
Table 4 Binary logistic regression model adjusted to the desired duration of breastfeeding. Variables
A
x2
OR (95% CI)
Women’s age Place of residence Education level Education level of the spouse SPC of the spouse Parity Number of prenatal visits Knowledge level Breastfeeding mode
0.104 0.753 0.708 0.092 0.146 0.021 0.020 1.137 1.527
0.132 3.934a 6.056a 0.136 0.088 0.003 0.006 8.547b 16.723c
1.109 0.471 0.493 1.097 1.158 0.979 1.020 3.119 0.217
(0.634; (0.224; (0.280; (0.672; (0.441; (0.442; (0.606; (1.455; (0.104;
1.942) 0.991) 0.866) 1.791) 3.038) 2.170) 1.716) 6.686) 0.451)
SPC: socioprofessional category; A: constant; x2: Wald; OR: odds ratio; CI: confidence interval. a P < 0.05. b P < 0.01. c P < 0.001.
breastfeed their babies, a percentage close to that recorded in the Hassani study (60%) [16]. Many (81%) of the women surveyed expressed breastfeeding choices for a duration of more than 12 months. In the present study, we also found a significant association between multiparity, the level of knowledge, desired breastfeeding mode, and sustained breastfeeding duration. Educated women are well aware of the benefits of breastfeeding but expressed a desired breastfeeding duration lower than that expressed by women who are illiterate or have a low level of education. In contrast to women’s education level, and because previous experience increases a woman’s confidence, multiparous women had a good level of breastfeeding knowledge and wished to breastfeed for longer periods [23]. 5. Conclusion
one consultation per quarter for women with no known pathological disease or history. In Morocco, three out of four consultations are planned for what is considered a normal pregnancy. In our survey 57.4% of the women investigated attended more than three prenatal visits; this percentage is lower than that reported by El Housni at the Souissi maternity center in Rabat, Morocco, who had found 65.76% [15]. The study of the benefits of breastfeeding, as mentioned by women, showed that 75% know at least one advantage. Among the most frequently mentioned benefits are those concerning, in order of priority, the baby’s and mother’s health, respectively 65.87% and 24.42%. These benefits are particularly well known in the women’s environment (family, friends) and media, respectively 52.8% and 37.5%, while the information is learned via medical staff for only 14% of the women, even though 57.4% attended prenatal visits more than four times. Certainly, information provided by healthcare staff is extremely important and can effectively contribute to the good start and long duration of breastfeeding; however, this part remains largely higher than that recorded by Hassani in the Souissi maternity in Rabat, Morocco (2%). [16]. These findings demonstrate the lack of strategy and communication to improve women’s knowledge on breastfeeding. In fact, being informed previously about the optimal modalities for the implementation of breastfeeding and the needs and behaviors of newborns facilitates the initiation of this practice in maternity wards, helps establish realistic expectations, and helps mothers meet the challenges of the first days and nights [17]. In addition, women’s knowledge of the benefits of breast milk appears to be related to their age; the older women are the more they know about the positive effects of breast milk. It is also noted that exclusive breastfeeding for a long time is most often chosen by the oldest women. Therefore, the results observed are consistent with those found in several studies, which demonstrated a significant association between the age of the mother and breastfeeding practice. After adjusting other factors, they even argued that mothers over the age of 25 are more likely to choose to breastfeed [18] and wish to breastfeed longer [19]. The level of knowledge is also significantly associated with women’s education level and parity. It is more satisfactory in multiparous than in primiparous women; this difference between these two groups of women could be attributed to the acquisition of experience by multiparous mothers. In addition, numerous studies have shown a very strong relation between breastfeeding intentions expressed before childbirth and the reality of breastfeeding [10,20,21], so the prenatal intention to breastfeed over a prolonged period was significantly associated with a prolonged feeding [16,20,22]. In our study, 57.6% of women expressed their intentions to exclusively
The results of this study showed the knowledge gap that exists among mothers about breastfeeding. Also, this study shows that a lack of information can affect the duration of breastfeeding, a behavior that can be modified by good information and real preparation of women, especially primiparous women and those with a low level of education, during prenatal and maternity consultations. Disclosure of interest The authors declare that they have no competing interest. Acknowledgments We would like to thank all the women who participated in this study. Special thanks are extended to the Marrakech Health Authority.
References [1] Haute Autorite´ de Sante´. Favoriser l’allaitement maternel. Processus-e´valuation. Paris: HAS; 2006. [2] Rollins NC, Bhandari N, Hajeebhoy N, et al. Why invest, and what it will take to improve breastfeeding practices? Lancet 2016;387:491–504. [3] Victora CG, Bahl R, Barros AJD, et al. Breastfeeding in the 21st century: epidemiology, mechanisms, and lifelong effect. Lancet 2016;387:475–90. [4] World Health Organization. Infant and young child feeding: model chapter for textbooks for medical students and allied health professionals. Geneva: World Health Organization; 2009. [5] Salanave B, de Launay C, Boudet-Berquier J, et al. Dure´e de l’allaitement maternel en France (E´pifane2012-2013). Bull Epidemiol Hebd 2014;27:450–7. [Accessed April 20, 2017]http://www.invs.sante.fr/beh/2014/27/2014272.html. [6] Unicef. La situation des enfants dans le monde 2015, 2015 http://www.data.unicef.org/corecode/uploads/document6/uploaded_pdfs/corecode/SOWC_2015_all-countries-update_214.xlsx Accessed April 14, 2017. [7] Ministe`re de la Sante´ [Maroc], ORC Macro, et Ligue des E´tats Arabes. 2005. Enqueˆte sur la Population et la Sante´ Familiale (EPSF) 2003-2004. Calverton, Maryland, USA: Ministe`re de la Sante´ et ORC Macro, mars 2005. [8] Ministe`re de la Sante´ [Maroc] DPRF. DPE. SEIS. Enqueˆte nationale sur la population et la sante´ familiale (ENPSF-2011), de´cembre 2012. www.sante.gov.ma/Documents/Enqueˆte%20.pdf [9] Noirhomme-Renard F, Noirhomme Q. Factors associated with breastfeeding duration for at least three months: a literature review. J Pe´diatr Pue´riculture 2009;22:112–20. [10] Peters E, Wehkamp KH, Felberbaum RE, et al. Breastfeeding duration is determined by only a few factors. Eur J Public Health 2006;16:162–7. [11] Bai Y, Middlestadt SE, Peng CYJ, Fly AD. Predictors of continuation of exclusive breastfeeding for the first six months of life. J Hum Lact 2010;26:26–34. [12] Kronborg H, Vaeth M. The influence of psychosocial factors on the duration of breastfeeding. Scand J Public Health 2004;32:210–6. [13] Ismail TAT, Muda WMW, Bakar MI. Intention of pregnant women to exclusively breastfeed their infants: the role of beliefs in the theory of planned behavior. J Child Health Care 2013;18:123–32. [14] Haut-commissariat au plan MAROC. Les indicateurs sociaux du Maroc 2013-2014, e´dition 2016. https://www.hcp.ma/downloads/Indicateurs-sociaux_t11880.html
E. Jasny et al. / Archives de Pe´diatrie 26 (2019) 285–289 [15] El Housni, Boussalwa E, Kharbach A. La surveillance pre´natale au Maroc, cas des femmes ayant accouche´ a` la maternite´ Souissi, CHU (Ibn Sina) Rabat. European Scientific J 2016;12:232–40. [16] Hassani A, Barkat A, Souilmi FZ, et al. La conduite de l’allaitement maternel. E´tude prospective de 211 cas a` la maternite´ Souissi de Rabat. J Pediatr Puer 2005;18:343–8. [17] Gremmo-Feger, G., Comment bien de´marrer l’allaitement maternel. 34e`me Journe´e de Pe´rinatalite´ Re´seau de pe´rinatalite´ de Franche-Comte´. Confe´rence du 15 Mars 2006, mis en ligne sur le site Co-naıˆtre en aout 2006. www.conaitre.net/wp-content/uploads/2016/04/demarrageallaitementGGFaug06.pdf [18] Ford K, Labbok M. Who is breast-feeding? Implications of associated social and biomedical variables for research on the consequences of method of infant feeding. Am J Clin Nutr 1990;52:451–6.
289
[19] Rutishauser IHE, Carlin JB. Body mass index and duration of breastfeeding: a survival analysis during the first six months of life. J Epidemiol Community Health 1992;46:559–65. [20] Blyth RJ, Creedy DK, Dennis CL, et al. Breastfeeding duration in an Australian population: the influence of modifiable antenatal factors. J Hum Lact 2004;20:30–8. [21] Lawrence RA, Lawrence RM. Breastfeeding: A guide for the medical profession. 6th Edition. St. Louis: Mosby; 2005. p. 1152. [22] DiGirolamo A, Thompson N, Martorell R, et al. Intention or experience? Predictors of continued breastfeeding. Health Educ Behav 2005;32:208–26. [23] Coreil J, Murphy JE. Maternel commitment, lactation practices, and breastfeeding duration. Jobstet Gynecol Neonatal Nurs 1988;17:237–8.
Available online at
ScienceDirect www.sciencedirect.com
Research paper
Mothers’ knowledge and intentions of breastfeeding in Marrakech, Morocco E. Jasny *, H. Amor, A. Baali Laboratory of Human Ecology, Faculty of Science Semlalia, Cadi Ayyad Marrakesh University, Prince Moulay-Abdellah street, 2390, Marrakesh, Morocco
A R T I C L E I N F O
A B S T R A C T
Article history: Received 23 May 2018 Received in revised form 12 March 2019 Accepted 22 May 2019 Available online 3 July 2019
Exclusive breastfeeding immediately after birth and during the first 6 months of life is the best source of nutrition for an infant. Its well-documented benefits are countless. Several studies highlight the relation between women’s knowledge of breastfeeding, their attitudes, and their subsequent behavior. In this perspective, we conducted a study to examine the intentions and prenatal knowledge of mothers on breastfeeding. In a survey conducted from September 2013 to June 2015, 768 women were interviewed in different maternity units in Marrakech and its surrounding rural area. The mothers’ mean age was 27.6 years, 30.1% of them were illiterate, and 48.2% were from rural areas. A total of 95.3% of the mothers received information concerning breastfeeding during pregnancy. The immediate circle of family and friends was the main source of information (52.8%), while healthcare professionals accounted for only 14%. Of the women surveyed, 57.5% had the intention during pregnancy to breastfeed their babies, and 81% wished to breastfeed for more than 12 months. The level of knowledge was related to the mother’s age, education level, and parity. It should be noted that as their age increases women tend to choose breastfeeding exclusively for long periods. The level of knowledge and intentions of mothers regarding breastfeeding are associated with the success of this practice; however, the rate of breastfeeding continues to decline both nationally and regionally. Therefore, several measures should be taken to promote breastfeeding.
C 2019 French Society of Pediatrics. Published by Elsevier Masson SAS. All rights reserved.
Keywords: Breastfeeding Knowledge Intentions Breastfeeding benefits Breastfeeding duration
1. Background Breastfeeding is the reference for infant feeding during the first months of life. It promotes the child’s physical and psychological development, privileges mother–child bonding, and strengthens immunity [1]. Many studies have indicated that breastfeeding improves children’s health, including lower rates of childhood infections and malocclusion, higher intelligence quotient scores, and lower rates of obesity and diabetes [2,3]. Recommendations agree that ideally, children should benefit from exclusive breastfeeding during the first 6 months or at least that weaning should not occur until 4–6 months [4]. The practice of breastfeeding is currently declining throughout the world. In France, the Abbreviations: CI, confidence intervals; SD, standard deviation; Lv, level of knowledge; OR, odds ratio; SPC, socioprofessional category; WHO, World Health Organization. * Corresponding author. E-mail address: [email protected] (E. Jasny).
E´pifane study reports that at 3 months, one infant out of three is breastfed and only 10% benefit from exclusive breastfeeding [5]. In Tunisia 9% of infants less than 6 months are exclusively breastfed, this same rate reached 27% in Lebanon in 2016 [6]. Morocco does not escape this phenomenon: breastfeeding has also been the subject of a worrying decline. In 1992, 51% of children were breastfed during the first 6 months of life, whereas this frequency was only 31% and 27.8% in 2004 and 2011, respectively [7,8]. At the regional level, the city of Marrakech is not an exception: according to the national survey on population and family health, the rate of exclusive breastfeeding is only 29% [8]. The factors that influence the practice of breastfeeding are numerous and complex, related for example to the mother herself (age, level of education, occupational activity, etc.) with her intentions and knowledge on breastfeeding [9], as well as her baby and its health status [10]. Moreover, several studies have underscored the link between women’s knowledge on breastfeeding, their attitude toward this way of feeding, and their subsequent behavior. Several studies have reported that women who had a
https://doi.org/10.1016/j.arcped.2019.05.007 C 2019 French Society of Pediatrics. Published by Elsevier Masson SAS. All rights reserved. 0929-693X/
286
E. Jasny et al. / Archives de Pe´diatrie 26 (2019) 285–289
positive attitude towards breastfeeding had extended length of exclusive breastfeeding time [11]. Indeed, women who know the benefits of breastfeeding would be more likely to choose it [12]. It has also been shown that the prenatal intention to breastfeed over a prolonged period is significantly associated with prolonged breastfeeding. The stronger the mother’s intention to breastfeed during the prenatal period, the more likely she is to breastfeed exclusively after the baby is born [13]. In addition, the objectives of the present study were to assess the knowledge and intentions towards the breastfeeding of a group of Moroccan postpartum mothers in the province of Marrakesh and to understand the socioeconomic, demographic, and healthrelated factors.
2. Subjects and methods 2.1. Study design This is a prospective and analytic cross-sectional survey. Our sample included a total of 768 women aged 17–46 years. The survey was conducted after obtaining permission from the Moroccan Ministry of Health and the Marrakech health authorities. All women provided oral consent before participating in the survey. We used a very detailed questionnaire, which was validated by the Marrakech health authorities and tested previously. The information was collected anonymously and confidentially. After their oral consent, women were interviewed during their postpartum stay in public maternity wards in Marrakech and its rural area, after delivery, between the 1st and 2nd postpartum day. The confidentiality of the data was respected. The questionnaire, which was the basis of the interview, contains items on the sociodemographic profile of the women interviewed (age, urban/rural origin, education level, parity) and several characteristics related to pregnancy and childbirth (follow-up and where the pregnancy was followed up, term, and mode of delivery). Women’s knowledge and attitudes towards breastfeeding were assessed through two questions: the first question concerns the benefits of breastfeeding. The women’s responses to this question were grouped into six main groups: infant health (protection against diarrhea infections, prevention of allergies, enhanced immunity, normal development during the 1st months of life), maternal health (protection against breast cancer and hemorrhage, uterine involution, loss of weight gained during pregnancy, contraceptive means), complete food (contains all necessary nutrients for the baby), accessible food (no preparation, adequate temperature, etc.), normal psychoaffective development of the infant (strengthening mother–child relationship, affection, etc.), and the economic advantages for the family. The level of women’s knowledge was established from the number of benefits mentioned. Thus, the women were classified into two groups: group 1 with an unsatisfactory level of knowledge (Lv1), including all women mentioning only one benefit, and group 2 with a medium to the satisfactory level of knowledge (Lv2), where women knew at least two advantages. The second question is related to the planned duration of breastfeeding the child: duration of breastfeeding less than 12 months and duration of breastfeeding more than or equal to 12 months. 2.2. Data analysis A descriptive analysis was performed using means and standard deviations (SD). To estimate the significance of the differences observed between the means, the Chi2 test was used for categorical variables.
Multivariate analysis was used to identify each factor independently associated with the level of women’s knowledge and with the desired breastfeeding duration. Associations were measured in odds ratios (OR) with 95% confidence intervals (95% CI). The statistical significance was set at P < 0.05. The statistical treatment of data was performed using SPSS software PC-FR, version 10. 3. Results 3.1. Sociodemographic characteristics of the sample studied The age of the women in the sample varied from 17 to 46 years, for a mean 27.6 years (SD, 6.27 years). The sample mostly comprised mothers less than 35 years old: 82.8% (36.5% less than 25 years old and 46.4% between 25 and 34 years of age). A total of 51.8% of the parturients were from urban areas and 48.2% from rural areas. The illiteracy rate among the women studied was 30.1% (n = 231). Among the literate women (n = 537), 33.9% had a primary school education level, 36.1% a secondary school and above education level. The illiteracy rate among spouses was 27.5%. Employment was very low since 93.4% (n = 717) of the women interviewed were jobless. The 6.6% remaining were employees (4.2%) and civil servants or senior managers (2.4%). Unlike women, the vast majority of spouses, 98.4%, were involved in professional activities. Among these spouses, 19% belonged to the socioprofessional category (SPC2) made up of civil servants and professionals, while the category consisting of day laborers, workers, personal service, employees, artisans, and small traders (SPC1) comprised the majority in our sample (81%). 3.2. Health characteristics Parity, estimated by the number of children per woman (including the newborn) varied from 1 to 7, with an average of 2.25 (SD, 1.2). The primiparous women accounted for 32.6% (n = 250) of the sample, while multiparous mothers accounted for 67.4% (n = 518). Among the women surveyed, 89.2% (n = 685) consulted at least once during pregnancy. Also, the number of prenatal visits varied from one to ten visits, for a mean four visits (4.2 1.74). Among these women (n = 688), 32.7% benefited from one to three prenatal visits and 57.4% more than three visits. In this sample, 54.3% of women had their pregnancies followed in a private structure, 26.4% in a public structure, and 19.3% in both structures. As for delivery, 80.7% of women delivered vaginally and 94.5% of babies were full term. 3.3. Women’s knowledge of the benefits of breastfeeding The number of breastfeeding benefits mentioned by women varied from one to five (mean, 1.96, SD, 0.93). Among the women surveyed, 4.7% knew no benefits of breast milk and 25% knew one advantage (n = 192), 46.2% two benefits (n = 355), and 24.1%, three benefits and more (n = 185). Among the benefits reported by women, breast milk’s superiority for better health of the baby came first (42.66%), followed by better maternal health (24.42%), the best food for normal psychoaffective development of infants (12.18%), a complete food (11.03%), an accessible food (7.26%), and economic advantages for the family (2.42%). The immediate environment (family, friends) was the main source of information for the women interviewed: 52.8%. Media are also an important source of information for 37.5% of mothers. Information received from healthcare professionals and acquired from previous experience of breastfeeding accounted for 14% and 10.3%, respectively.
E. Jasny et al. / Archives de Pe´diatrie 26 (2019) 285–289 Table 1 Medium to satisfactory level of women’s knowledge and sociodemographic and health characteristics. Variables
Modalities
Women’s age
< 25 280 25–34 356 35 132 Urban 398 Rural 370 Illiterate 231 Primary 260 Secondary and more 277 Illiterate 211 Primary 222 Secondary and more 313 SPC1 617 SPC2 145 Primiparous 250 Multiparous 518 None 76 1–3 visits 251 4 visits 441
Place of residence Education level
Education level of the spouse
SPC of the spouse Parity Number of prenatal visits
Number
Lv2
x2 test
60.7 75.0 78.0 72.4 68.1 59.7 66.2 83.0 67.8 68.5 75.7 69.4 75.9 54.0 78.2 63.2 69.7 71.9
19.87a
1.66 ns 35.99a
5.14 ns
2.38 ns 47.25a 2.8 ns
ns: not significant; SPC: socioprofessional category; Lv2: a medium to satisfactory level of knowledge; SPC1: socioprofessional category consisting of day laborers, workers, personal service, employees, artisans and small traders; SPC2: socioprofessional category made up of civil servants and professionals. a P < 0.001.
The relation between the level of the women’s knowledge on breastfeeding benefits and sociodemographic and health characteristics is given in (Table 1). The level of women’s knowledge was established from the number of benefits mentioned. It appears that only parity, the woman’s education level, and then her age were statistically linked to her level of knowledge. To summarize the determining factors of the level of knowledge of the women studied, we carried out a binary logistic regression analysis (Table 2). The dependent variable corresponds to two levels of women’s knowledge on the benefits of breast milk (unsatisfactory and medium to satisfactory). The independent variables are related to the sociodemographic and health variables discussed above. The results of this analysis confirm those of the bivariate analysis (Table 1). Indeed, only the women’s education level, parity, and age variables appear to be positively associated with women’s knowledge on breast milk benefits. 3.4. Women’s intentions regarding breastfeeding The question related to the desired mode of breastfeeding was answered as follows: 57.5% said that they would adopt exclusive breastfeeding and 34.4% mixed feeding; the remaining 8.1% were undecided.
Table 2 Binary logistic regression model adjusted from medium to high knowledge level of mothers. Variables Women’s age Place of residence Education level Education level of the spouse SPC of the spouse Parity Number of prenatal visits
A 0.451 0.115 0.818 0.036 0.003 1.223 0.087
x2 10.443 0.360 37.558b 0.086 0 38.949b 0.420
1.569 1.122 2.266 1.037 1.003 3.399 1.091
(1.194; (0.770; (1.744; (0.815; (0.603; (2.314; (0.838;
3.5. Desired breastfeeding duration Of the women studied, 81% wanted to breastfeed their babies for more than 12 months, 6% for less than 12 months, and 13% were indecisive at the time of the survey. The study of the associations between the targeted duration of breastfeeding and the sociodemographic and health variables shows that only the women’s parity, their level of knowledge about the benefits of breast milk, and the mode of breastfeeding desired were significantly related to the duration of breastfeeding (Table 3). Indeed, women with a moderate to satisfactory level, multiparous women, and women who had chosen an exclusive breastfeeding mode wished to breastfeed for a period of 12 months or more. In a binary logistic regression model, the dependent variable was the duration of breastfeeding desired. The independent variables were sociodemographic and health variables studied above. This shows that the breastfeeding mode chosen, the mother’s level of knowledge, place of residence, and education level are independently linked to the desired duration of breastfeeding (Table 4). 4. Discussion The assessment of prenatal knowledge and the intentions of women regarding breastfeeding in our study affected 768 women who gave birth in various maternity units in the province of Marrakech. The sample consists for the most part of young women aged less than 35 years (82.8%). The illiteracy rate in this study was 30.1%, which is lower than in the Marrakech-Safi region in 2014 (42.1%). [14] The average number of children per woman was 2.2, very close to that recorded at the regional level in the same period (2.5%) [14]. Important for a healthy pregnancy, follow-up provides an opportunity to prepare the future mother for breastfeeding. In this study, 89.1% of women reported having had the pregnancy followed. Among these pregnancies, 57.4% had an adequate number of prenatal visits, which corresponded to more than four visits [14]. WHO has established the follow-up timing as at least Table 3 Desired breastfeeding duration and sociodemographic and health characteristics of women. Variables
Modalities
N
12
x2 test
Women’s age
< 25 25–34 35 Urban Rural Illiterate Primary Secondary and more Illiterate Primary Secondary and more SPC1 SPC2 Primiparous Multiparous None 1–3 visits 4 visits Unsatisfactory (Lv1) Medium to satisfactory (Lv2) Exclusive breast Mixed
237 314 115 342 324 202 226 238 189 190 271 540 124 200 466 66 223 377 176 490 404 215
91.6 93.9 93.9 94.2 92.0 94.6 94.7 90.3 92.6 95.8 91.5 93.0 94.4 90.0 94.4 95.5 92.8 92.8 88.1 94.9 97 87
1.3 ns
Place of residence Education level
Education level of the spouse SPC of the spouse Parity
OR (95% CI) a
2.062) 1.634) 2.944) 1.319) 1.670) 4.990) 1.419)
A: constant; x2: Wald; OR: odds ratio; CI: confidence interval; SPC: socioprofessional category. a P < 0.01. b P < 0.001.
287
Number of prenatal visits Knowledge level Breastfeeding mode
1.22 ns 4.38 ns
3.26 ns
0.3 ns 4.25a 0.63 ns
9.39a 26.46b
ns: not significant; 12: duration of breastfeeding equal to or greater than 12 months; SPC: socioprofessional category. a P < 0.01. b P < 0.001.
E. Jasny et al. / Archives de Pe´diatrie 26 (2019) 285–289
288
Table 4 Binary logistic regression model adjusted to the desired duration of breastfeeding. Variables
A
x2
OR (95% CI)
Women’s age Place of residence Education level Education level of the spouse SPC of the spouse Parity Number of prenatal visits Knowledge level Breastfeeding mode
0.104 0.753 0.708 0.092 0.146 0.021 0.020 1.137 1.527
0.132 3.934a 6.056a 0.136 0.088 0.003 0.006 8.547b 16.723c
1.109 0.471 0.493 1.097 1.158 0.979 1.020 3.119 0.217
(0.634; (0.224; (0.280; (0.672; (0.441; (0.442; (0.606; (1.455; (0.104;
1.942) 0.991) 0.866) 1.791) 3.038) 2.170) 1.716) 6.686) 0.451)
SPC: socioprofessional category; A: constant; x2: Wald; OR: odds ratio; CI: confidence interval. a P < 0.05. b P < 0.01. c P < 0.001.
breastfeed their babies, a percentage close to that recorded in the Hassani study (60%) [16]. Many (81%) of the women surveyed expressed breastfeeding choices for a duration of more than 12 months. In the present study, we also found a significant association between multiparity, the level of knowledge, desired breastfeeding mode, and sustained breastfeeding duration. Educated women are well aware of the benefits of breastfeeding but expressed a desired breastfeeding duration lower than that expressed by women who are illiterate or have a low level of education. In contrast to women’s education level, and because previous experience increases a woman’s confidence, multiparous women had a good level of breastfeeding knowledge and wished to breastfeed for longer periods [23]. 5. Conclusion
one consultation per quarter for women with no known pathological disease or history. In Morocco, three out of four consultations are planned for what is considered a normal pregnancy. In our survey 57.4% of the women investigated attended more than three prenatal visits; this percentage is lower than that reported by El Housni at the Souissi maternity center in Rabat, Morocco, who had found 65.76% [15]. The study of the benefits of breastfeeding, as mentioned by women, showed that 75% know at least one advantage. Among the most frequently mentioned benefits are those concerning, in order of priority, the baby’s and mother’s health, respectively 65.87% and 24.42%. These benefits are particularly well known in the women’s environment (family, friends) and media, respectively 52.8% and 37.5%, while the information is learned via medical staff for only 14% of the women, even though 57.4% attended prenatal visits more than four times. Certainly, information provided by healthcare staff is extremely important and can effectively contribute to the good start and long duration of breastfeeding; however, this part remains largely higher than that recorded by Hassani in the Souissi maternity in Rabat, Morocco (2%). [16]. These findings demonstrate the lack of strategy and communication to improve women’s knowledge on breastfeeding. In fact, being informed previously about the optimal modalities for the implementation of breastfeeding and the needs and behaviors of newborns facilitates the initiation of this practice in maternity wards, helps establish realistic expectations, and helps mothers meet the challenges of the first days and nights [17]. In addition, women’s knowledge of the benefits of breast milk appears to be related to their age; the older women are the more they know about the positive effects of breast milk. It is also noted that exclusive breastfeeding for a long time is most often chosen by the oldest women. Therefore, the results observed are consistent with those found in several studies, which demonstrated a significant association between the age of the mother and breastfeeding practice. After adjusting other factors, they even argued that mothers over the age of 25 are more likely to choose to breastfeed [18] and wish to breastfeed longer [19]. The level of knowledge is also significantly associated with women’s education level and parity. It is more satisfactory in multiparous than in primiparous women; this difference between these two groups of women could be attributed to the acquisition of experience by multiparous mothers. In addition, numerous studies have shown a very strong relation between breastfeeding intentions expressed before childbirth and the reality of breastfeeding [10,20,21], so the prenatal intention to breastfeed over a prolonged period was significantly associated with a prolonged feeding [16,20,22]. In our study, 57.6% of women expressed their intentions to exclusively
The results of this study showed the knowledge gap that exists among mothers about breastfeeding. Also, this study shows that a lack of information can affect the duration of breastfeeding, a behavior that can be modified by good information and real preparation of women, especially primiparous women and those with a low level of education, during prenatal and maternity consultations. Disclosure of interest The authors declare that they have no competing interest. Acknowledgments We would like to thank all the women who participated in this study. Special thanks are extended to the Marrakech Health Authority.
References [1] Haute Autorite´ de Sante´. Favoriser l’allaitement maternel. Processus-e´valuation. Paris: HAS; 2006. [2] Rollins NC, Bhandari N, Hajeebhoy N, et al. Why invest, and what it will take to improve breastfeeding practices? Lancet 2016;387:491–504. [3] Victora CG, Bahl R, Barros AJD, et al. Breastfeeding in the 21st century: epidemiology, mechanisms, and lifelong effect. Lancet 2016;387:475–90. [4] World Health Organization. Infant and young child feeding: model chapter for textbooks for medical students and allied health professionals. Geneva: World Health Organization; 2009. [5] Salanave B, de Launay C, Boudet-Berquier J, et al. Dure´e de l’allaitement maternel en France (E´pifane2012-2013). Bull Epidemiol Hebd 2014;27:450–7. [Accessed April 20, 2017]http://www.invs.sante.fr/beh/2014/27/2014272.html. [6] Unicef. La situation des enfants dans le monde 2015, 2015 http://www.data.unicef.org/corecode/uploads/document6/uploaded_pdfs/corecode/SOWC_2015_all-countries-update_214.xlsx Accessed April 14, 2017. [7] Ministe`re de la Sante´ [Maroc], ORC Macro, et Ligue des E´tats Arabes. 2005. Enqueˆte sur la Population et la Sante´ Familiale (EPSF) 2003-2004. Calverton, Maryland, USA: Ministe`re de la Sante´ et ORC Macro, mars 2005. [8] Ministe`re de la Sante´ [Maroc] DPRF. DPE. SEIS. Enqueˆte nationale sur la population et la sante´ familiale (ENPSF-2011), de´cembre 2012. www.sante.gov.ma/Documents/Enqueˆte%20.pdf [9] Noirhomme-Renard F, Noirhomme Q. Factors associated with breastfeeding duration for at least three months: a literature review. J Pe´diatr Pue´riculture 2009;22:112–20. [10] Peters E, Wehkamp KH, Felberbaum RE, et al. Breastfeeding duration is determined by only a few factors. Eur J Public Health 2006;16:162–7. [11] Bai Y, Middlestadt SE, Peng CYJ, Fly AD. Predictors of continuation of exclusive breastfeeding for the first six months of life. J Hum Lact 2010;26:26–34. [12] Kronborg H, Vaeth M. The influence of psychosocial factors on the duration of breastfeeding. Scand J Public Health 2004;32:210–6. [13] Ismail TAT, Muda WMW, Bakar MI. Intention of pregnant women to exclusively breastfeed their infants: the role of beliefs in the theory of planned behavior. J Child Health Care 2013;18:123–32. [14] Haut-commissariat au plan MAROC. Les indicateurs sociaux du Maroc 2013-2014, e´dition 2016. https://www.hcp.ma/downloads/Indicateurs-sociaux_t11880.html
E. Jasny et al. / Archives de Pe´diatrie 26 (2019) 285–289 [15] El Housni, Boussalwa E, Kharbach A. La surveillance pre´natale au Maroc, cas des femmes ayant accouche´ a` la maternite´ Souissi, CHU (Ibn Sina) Rabat. European Scientific J 2016;12:232–40. [16] Hassani A, Barkat A, Souilmi FZ, et al. La conduite de l’allaitement maternel. E´tude prospective de 211 cas a` la maternite´ Souissi de Rabat. J Pediatr Puer 2005;18:343–8. [17] Gremmo-Feger, G., Comment bien de´marrer l’allaitement maternel. 34e`me Journe´e de Pe´rinatalite´ Re´seau de pe´rinatalite´ de Franche-Comte´. Confe´rence du 15 Mars 2006, mis en ligne sur le site Co-naıˆtre en aout 2006. www.conaitre.net/wp-content/uploads/2016/04/demarrageallaitementGGFaug06.pdf [18] Ford K, Labbok M. Who is breast-feeding? Implications of associated social and biomedical variables for research on the consequences of method of infant feeding. Am J Clin Nutr 1990;52:451–6.
289
[19] Rutishauser IHE, Carlin JB. Body mass index and duration of breastfeeding: a survival analysis during the first six months of life. J Epidemiol Community Health 1992;46:559–65. [20] Blyth RJ, Creedy DK, Dennis CL, et al. Breastfeeding duration in an Australian population: the influence of modifiable antenatal factors. J Hum Lact 2004;20:30–8. [21] Lawrence RA, Lawrence RM. Breastfeeding: A guide for the medical profession. 6th Edition. St. Louis: Mosby; 2005. p. 1152. [22] DiGirolamo A, Thompson N, Martorell R, et al. Intention or experience? Predictors of continued breastfeeding. Health Educ Behav 2005;32:208–26. [23] Coreil J, Murphy JE. Maternel commitment, lactation practices, and breastfeeding duration. Jobstet Gynecol Neonatal Nurs 1988;17:237–8.