Breast feeding indicators in Sudan: A case study of Wad Medani town

Breast Feeding Indicators in Sudan Haroun et al

Sudanese Journal of Public Health: April 2008, Vol.3 (2) 81

Original Article Breast feeding indicators in Sudan: A case study of Wad Medani town Huda Mohamed Haroun1 MDCH, Mohamed Salih Mahfouz2 PhD (Statistics) and Bassam Younis Ibrahim3

PhD (Statistics) 1 Associate Professor and Director of Health Services, University of Gezira, Wad Medani, Sudan. Director of Paediatrics Teaching Hospital, Wad Medani, Sudan. Tel: +249912552418, Fax: +248511843415. email: [email protected] 2 Associate Professor and Director of Population Studies Centre, University of Gezira, Wad Medani, Sudan 3 Associate Professor and Head Department of Applies Statistics, College of Science, Sudan University of Science and Technology. Khartoum, Sudan Abstract

This study aimed at determining the breastfeeding indicators, examining the effect of some demographics and

socio-economic factors on breastfeeding duration and at identifying the most important reasons that led mothers

to stop breastfeeding and wean their children before two years in Wad-Medani town, Gezira state.

The study relied on primary data collected through structured questionnaire designed to cover all research

objectives. Descriptive as well as inferential statistics techniques were utilized. The statistical Package for

Social Science (SPSS) was used to analyze the data.

The results revealed that the majority of the mothers 64.4% breast natural breastfeeding for full four months.

Also, 54.2% of them initiated breastfeeding after one hour from delivery. It was clear that the main reason led

the mothers to wean their infants was pregnancy 54.1%. Further the results suggested a significant association

between breastfeeding duration and some variables such as age of the mother, mother occupation, pregnancy

and family income are all.

The study recommended encouraging breastfeeding and educating mothers and especially pregnant women that

pregnancy does not harm the suckling child.

Keywords:

Introduction

Breastfeeding is defined as the process of feeding

an infant or young child with milk from mother

breasts. Babies have a suckling urge that enables

them to take in the milk, provided there is a good

latch, a normal frenulum, and milk supply (1).

It is only recently that modern scientific researches

have brought to light the paramount importance of

the breastfeeding to the health of child and mother.

Islam has known and emphasized this fact before

some 1400 years: the versus from Al-Ahqaf:

ووصينا الإنسان بوالديه إحسانا حملته أمه كرها ووضـعته "

ثون شهرا حتى إذا بلغ أشده وبلـغ كرها وحمله وفصاله ثال

نعمـت أربعين سنة قال رب أوزعني أن أشكر نعمتك التي أ

علي وعلى والدي وأن أعمل صالحا ترضاه وأصلح لي في

.(2)" ذريتي إني تبت إليك وإني من المسلمين

Several global and national organization (3-8),

including UNICEIF and WHO acknowledge

breastfeeding as the Gold Standard of infant

feeding. In 1990 WHO and UNICEIF jointly

adopted the Innocenti declaration, on the protection,

promotion and support of breastfeeding. (9)

UNICEIF and WHO recommended that all mothers

should breastfeed their babies exclusively for six

months and continue breastfeeding complemented

by other appropriate foods, up to the second year of

life (10). Breastfeeding is important not only for

child health and survival but it is an important

determinant of fertility, and mother health (11).



Evidence showed the increasing beneficial effects

of breastfeeding, it provides the ideal food for

normal growth and development of infant in term of

nutrition, protection from diarrhoeal diseases (12-14),

respiratory tract (15-18) and urinary tract infections (19), as well as neonatal infections (20). It reduces the

incidence of asthma and other a topyla (21-23), it

protects against obesity (24,25) diabetes mellitus (26),

hypertension, and hence vascular diseases (27).

Economically it reduces the population growth (11)

and hospital cost of admission for respiratory

infections and diarrhoeal diseases (13,28). It promotes

intelligence and cognitive development (29,30).

In Sudan as well as in developing countries children

are suffered from high risk of death due to poor

infant feeding and malnutrition. Nearly all women

can breastfeed if they are supported to be confident

and aware of good techniques and promotion of

practices (30). There are many factors which

determine the breastfeeding practices and make

women fail to complete the two years of

breastfeeding.

The main objectives of this study are to determine

breastfeeding indicators in Wad Medani town and

to identify the main socioeconomic and

demographic factors that determine the duration of

breastfeeding period.

Material and Methods

Wad-Medani town is the capital of the Gezira State.

It is the second largest town in Sudan and lies along

the bank of the Blue River Nile. Wad-Medani is of

430.487 population, 214.670 males and 215.817

females (CBS, 2007). The population of Wad-

Medani is considered a mixture of different tribal

categories of Sudan; most of them are government

employees, traders, farmers, and marginal jobs. The

average health situation in Wad-Medani town is

better than the national average and also better than

any other towns in Sudan.

The data of this study come from a household

survey conducted in September 2007.Questinnaire

was used to collect data from a sample 166 women

who have at least one child one year. A simple

random sampling technique was used with

anticipated population on proportion estimated to

yield a sample of 166 women to be investigated.

The questionnaire designed to obtain two types of

data socioeconomic data, and breastfeeding practice

information.

After the set of data were collected using

questionnaire, the data were coded and organized;

the Statistical Package for social science (SPSS)

was used to analyze the data. General tabulations

including frequency distribution were used. Also

chi-square test was used to test some associations

between the dependent variable breastfeeding

duration and a set of independent variables. More

over multiple linear regression is utilized to study

the determinants of the duration of breastfeeding

practice.

Results

Table (1) shows mother’s, occupational,

educational status and family expenditure. The

table showed that 82.5% of the women are house

wives 15.1% are employees, 1.2% for both workers

and business women. Regarding the educational

status, it was found that, 39.2% were secondary

educated, 24.1% were primary, 15.1 university

graduates 13.9% were intermediate and 4.1% are

illiterate It further presents the family expenditure

per day. Majority of family's expenditure was less

than 20 Sudanese Pounds (SDG) 58.5%.

Expenditure of 18.7% of the families lies between

20 to 29 SDG, 13.2% spends between 30 to 49

SDG. Only 9.6% of the families enjoy expenditure

more than 50 SDG. It is evident that the majority of

the women belong to poor families.



Table 1: Mother’s Occupational, Educational Status and family expenditure

Characteristics Number (n) Percentage (%) Mother’s Occupation Employer 25 15.1 Worker 2 1.2 Housewife 13 82.5 Business 2 1.2 Mother’s Educational Status Illiterate 7 4.2 khalwa 6 3.6 Primary 49 24.1 Intermediate 23 13.9 Secondary 65 39.2 University and above 25 15.1 Family Daily Expenditure (SDG) 1-9 34 20.5 10-19 63 38.0 20-29 31 18.7 30-39 20 12.0 40-49 2 1.2 50+ 16 9.6 Total 166 100 Table (2) illustrates distribution of mothers

according to age groups, contraceptive use and

contraceptives methods. The relatively large

percentages of mothers are in age groups from 25 to

40 years, which indicates a young age structure.

The table also shows the distribution of mothers

who are currently using family planning. The

distribution showed that 56.6% of them were

current user, while not users were 43.4%. Further

the users were asked to determine the type of

contraceptives. The majorities are using pills 42%,

only 6% and 5.4% used safe period and injections

respectively, while 1.8% of the mothers used Intra

Uterine Device (IUD). Condoms were rarely used

by the woman since only one woman is using

condoms. Table 2: Some demographic characteristics of the mothers

Characteristics Number (n) Percentage (%) Distribution of Age of the mothers 15-19 4 2.4 20-24 19 11.4 25-29 39 23.5 30-34 51 3.7 35-39 40 24.1 40-44 10 6.0 45-49 3 1.8 Contraceptive Use Yes 94 56.6 No 72 43.4 Contraceptives Type Pills 71 42.8 Injections 9 5.4 IUD 3 1.8 Condom 1 0.6 Safe period 10 6.0 NA 72 43.4 Total 166 100 Distribution of the number of children born last two

years and children ever born by age are presented in

table (3). The data showed that early child bearing

is relatively low sine only about 2.2% of births are

belonging to teenagers from 15 to19. The

corresponding figures for currently married women

31.2% for the age group from 30 to 34. On the

other hand column five summarizes the mean

children ever born. It provides good indicator for

cumulative fertility. For example on the average

women have given birth to at least three children by

their late 20s, and more than 7 children by the end

of childbearing ages reflecting the natural fertility

building process. All women have had, on average



3.9 children. Generally these figures of current and

cumulative fertility indicate a high fertility level

among the studied women.

Table 3 Fertility of the mothers

Age groups Number of women Births during last two years Children ever born Mean children ever born 15-19 4 04 (02.2% ) 6 1.5 20-24 19 22 (11.8% ) 46 2.4 25-29 39 41 (22.0%) 115 2.9 30-34 51 58 (31.2%) 191 3.7 35-39 40 48 (25.8%) 196 4.9 40-44 10 10 (05.4%) 58 5.8 45-49 3 03 (01.6%) 22 7.3 Total 166 186 (100%) 634 3.9 Breastfeeding Practice: All mothers were asked

when they initiated breastfeeding after child birth.

The majority of them initiated breastfeeding after

one hour from delivery 54.2%, and 39.7% of them

initiated breastfeeding during the period from two

hours to 24 hours. Only 6.0% of the mothers

initiated breastfeeding after one day (table 4).

Table (4) also illustrated the distribution of natural

breastfeeding practice as well as the duration of

breast feeding in months. It is clear from the table

that woman who exclusively breastfeeding for full

four months are the majority, consisting 64.5%.

Those who breastfeed for six months were 29.5%,

while only 6.0% breastfeed for two months.

Table (4) also showed the distribution of

breastfeeding duration. It is clear that the majority

of the mothers stopped breastfeeding during the

period between 19 to 24 months, 21.2% of them

stopped breastfeeding before one year and 25%

stopped breastfeeding during the period 13 to 18

months.

Table 4: Breast Feeding Practice

Characteristics Number (n) Percentage (%) Initiation of Breastfeeding After one hour 90 54.2 Two hour to 23 hours 66 39.7 After one day 10 6.0 Exclusive Breastfeeding Two Months 10 6.0 Four Months 107 64.5 Six Months 49 29.5 Duration of Breastfeeding 1-6 Months 10 6.0 7-12 Months 26 15.7 13-18 Months 40 24.1 19-24 Months 80 48.2 24 Months and above 10 6.0 Initiation of Breastfeeding After one hour 90 54.2 Two hour to 23 hours 66 39.7 After one day 10 6.0 Age for complementary food After four months 17 10.2 After six months 149 89.8 Food type Traditional Sudanese food 150 90.4 Ready made food 16 9.6 Bottle Usage Used 34 20.5 Not used 132 79.5 Total 166 100 The study found that exclusive breastfeeding was

ranged between four and six months because most

mothers give their infants complementary food after

six months 89.8% and only 10.2 % after four

months (table 4).



Regarding food type and according to table (4), the

majority of the mothers give their children

Sudanese food more than 90%, while only 10% of

the women gave ready made food for their children.

On the other hand 20.5% of the mothers stated that

they use bottle for their children.

Figure (1) illustrates the main reasons which lead

the mothers to stop breast feeding. It was clear that

the main reason led the mothers to wean their

infants was pregnancy 54.1%. Some mothers

stopped breastfeeding their children because their

health was not helpful to continue breastfeeding

15.5%. Others argued that they stopped

breastfeeding for cultural beliefs 9%. Only 5.5%

stopped breastfeeding for work and little milk.

Figure (1): Reasons for stopping breastfeeding

54.10

6.56

15.57

8.20 9.026.56

0.00

10.00

20.00

30.00

40.00

50.00

60.00

Pregenancy Few milk Health of themother

Health of thechild

Traditions andCluture

Work

Pecentages

Associations Between breastfeeding Duration

and Some Selected Variables: In this part cross

tabulation for most important variables related to

breastfeeding duration are presented. In each case a

test of independence was performed using χ2 (Chi-

square) test of independency. The independent

variables that assumed to affect the duration of

breastfeeding (dependent variable) are age of

mother, education of the mother, parity, mother’s

occupation, pregnancy, family expenditure and

contraceptives use.

Table (5) shows that, age of the mother, mother

occupation, pregnancy and family income are all

significant. This means that these variables are

associated with the breastfeeding duration. On the

other hand, mother's education, parity,

contraceptive use turned out to be has no

association with the duration of breastfeeding.



Table 5: Association between breastfeeding duration and some selected variables

No. Independent Variable χ2 Value Significance 1 Age of the mother 127.0 0.000** 2 Mother's Education 4.50 0.290 3 Parity 5.12 0.231 4 Mother's occupation 12.05 0.030* 5 Pregnancy 6.96 0.040* 6 Family Expenditure 6.03 0.049* 7 Contraceptive Use 2.13 0.340 * Significant at 5% level ** Significant at 1% level Regression Analysis: To dig deeper analyzing the

determinants of breastfeeding duration, a multiple

linear regression model was built, to test the

influence of a set of independent variables on the

dependent variable (breastfeeding duration). It is

therefore necessary to make an analysis that can

clearly show to what extent each one of the

explanatory variables affects the duration of

breastfeeding. The following equation describes

this relationship.

iy x x x x d d d1 1 2 2 3 3 4 4 5 1 6 2 7 3= β + β + β + β + β + β + β +Ψ Where:

Y = Breastfeeding duration.

X1= Age of mothers;

X2 = Parity of the mother;

X3 = Mothers years of education;

X4 = family monthly expenditure;

10 if th e m o th e r n o t p re g re n a n t

D =1 if th e m o th e r p re g re n a n t

20 i f t h e m o t h e r i s h e a l t h y

D =1 o t h e r w i s e

30 i f th e m o th e r n o t w o rk in g

D =1 o th e rw is e

iΨ = Error term (assumed to be distributed normal

distribution).

76544321 ,,,,,, ββββββββ and ,

are the partial regression coefficients.

The estimated equation is given bellow are figures

between practice indicate t values:

( ) ( ) ( ) ( ) ( ) )5.3(57.05.45.398.)25.1(25.1403.401.25.4005.080.040.075.0ˆ 3214321

−−−−−+−+−−= dddxxxxy

R2 = 0.93 F ratio = 280.0 with P value = 0.000

From the estimated equation, the overall model is

significant at 1% level (P value = 0.00). All the

expected signs are confirmed by the empirical

results. R2 or coefficient of determination revealed

that 93% of the variation in duration of

breastfeeding was explained by the set of the

explanatory variables. A close examination of the

model confections indicates that mother age is

significant at 1% level (P value = 0.000).

Pregnancy is also a highly significant variable at

1% level (P value = 0.001) followed by mother's

occupation at 5% level (P value = 0.01) and family

income at 5% level (P value = 0.03).

On the other hand mother's education turned to be

insignificant (P value = 0.23). The mother health

also was not significant variable affecting

breastfeeding duration (P value = 0.34). Parity has

no significant effect on the duration of

breastfeeding (P value = 0.45).

In conclusion our model supports the results

obtained by Chi-square test, which indicate that

among these variables age of mother, pregnancy,

mothers occupation and family expenditure were

influencing breast-feeding and hence strong

determinant of it duration.

Discussion

Conventional wisdom, supported by scientific

research, advocates breastfeeding as superior

method of infant feeding. The nutrition,

immunological, psychological, and general health

advantages conveyed to notes have been

documented for years. The merits of human breast

milk as compared to artificial feeds include ideal

nutrition content, better absorption, fewer food-



related allergies, more favorable psychological

development, better immunologic defenses, and a

substantial economic advantage. There is another

compelling benefit to exclusive breastfeeding:

positive effects on the development of an infant's

oral cavity, including improves shaping of the hard

palate resulting in proper alignment of teeth and

fewer problems with malocclusions (31,32).

Breastfeeding is a natural impulse of all mothers as

it allows them to express their love, tenderness and

protection of their children. Islam recognizes and

highlights this fact as the previously mentioned

verse of the holy Quran instructed. WHO and

UNICEIF have recommended initiation of breast

feeding within the first hour of life .exclusive

breastfeeding for six months and should be

continued with appropriate complementary food for

two years (33).

Studying these indicators, we found that 54.2% of

mothers started breastfeeding their children within

one hour which is similar to the result of save

motherhood survey conducted in Sudan in 1999

(SMS), where two thirds of mothers were initiated

breastfeed in the first hour of life. It also similar to

Middle East and North Africa, Sub-Saharan Africa

and Asian countries and higher than North America

and Europe (34). The importance of early initiation

of breastfeeding come from the fact that early skin

to skin contact is associated with more affectionate

behavior of mother towards her infant that decrease

the rate of breastfeeding problems (33). Desirable

rate of exclusive breastfeeding still distant goal as

in most of the Arab world. Sudan tailed them, its

exclusive rate for six month in our study is 29.4%

which is lower than Egypt and Syria but similar to

some high income Gulf Arabian counties, and some

Sub-Saharan countries .It also lower than some

Asian countries (35). Exclusive breastfeeding rates

by UN regions are 25% in Africa, 45% in Asia, and

31% in Latin America (36). The prevalence of

breastfeeding between one year and 15 months is

relatively high in all regions Africa, Asia ,and Latin

America which dropped for children 18 to 24

months in Latin America, Caribbean and Near

East/North Africa to about 25%. In sub-Saharan

Africa and Asia is relatively high over 50% (36,44). In

our study the rates are similar to SMS and sub-

Saharan Africa where the majority of mothers

breastfeed their children more than 18 months.

Factors that determine stoppage of breastfeeding in

our study are headed by mother get pregnant more

than 50% of mothers have a misconception that

pregnancy has an ill effect on fetus this finding

seems to be characteristic for Sudan and shared

others Middle East and Asian, countries (37-39).

Other factors that influence breastfeeding duration

are work of the mother, and insufficient milk which

are similar to studies in some Arab countries (37,40,41). And differ from Europe and North America

where the main determinant factor is the decision of

the mother to breast feed her child (42,43).

Bottle feeding carries a significant risk of morbidity

because of bottle contamination, and is therefore a

useful indicator to follow. Bottle feeding is highly

variable depending on the region it is lowest in

Sub-Saharan Africa, although it is 30% in Namibia

and Nigeria. In Latin America and Caribbean rates

are very high .whereas rates are much lower

In Asia 9.2% in India (43,44). In our study bottle

feeding is about 20.5% which is similar to Sub-

Saharan Africa, and Near East/North Africa (44).

In our study most mothers used to give their

children home made food, which is good, but they

need to be counseled to fit with the national

recommendations.

Conclusion

The present work indicates that mothers' practices

related to breastfeeding in Wad Medani town are

still not to optimum, efforts should be made to

change bad behavior and reinforce good ones.



Health education programmers for breastfeeding

promotion should address the barriers for achieving

high rates of breastfeeding indicators taking the

advantages of the Quranic advice. Working mothers

should be encouraged by providing facilities for

breastfeeding in the work place paid maternal leave

for six months to achieve exclusive breastfeeding.

WHO/UNICEF, Baby Friendly Hospital Initiative

must be adopted in all maternity and pediatrics

hospital. Universities can introduce breastfeeding

promotion as part of community courses.

Community leaders, Imams also should advocate

for breastfeeding as part of their talk in mosque.

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Breast feeding indicators in Sudan: A case study of Wad Medani town

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