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Background: Despite consistent evidence showing the importance of exclusive breastfeeding (EBF) for six months, it remains a sub-optimal practice in The Gambia. This study aimed at investigating the determinants of EBF knowledge and intention to or practice of EBF. Methods: A cross-sectional study was conducted among 334 women receiving care at the Edward Francis Small Teaching Hospital (EFSTH) from December 2015 to February 2016. Using a structured interviewer-administered questionnaire, knowledge on EBF was determined and scored. Participants scoring above or equal to the median were determined to have sufficient EBF knowledge. Multivariate logistic regression analyses were used to identify predictors of EBF knowledge and intention to or practice of exclusive breastfeeding. Results: The proportion of women with sufficient exclusive breastfeeding knowledge and intended to or practice EBF were 60.2% and 38.6% respectively, while only 34.4% received EBF counseling. Earning ≥1500 GMD monthly (Adjusted Odds Ratio [aOR] 1.98; 95% Confidence Interval [Cl] 1.24, 3.16), having positive attitude (aOR 2.40; 95% Cl 1.40, 4.10) and partner supporting EBF (aOR 2.18; 95% Cl 1.23, 3.87) predicted sufficient EBF knowledge. Mothers aged 26-34years (aOR 0.50; 9 5% Cl 0.31, 0.82) and EBF counseling (aOR 2.68; 95% Cl 1.68, 4.29) significantly associated with intention to or practice of exclusive breastfeeding. Conclusion: In conclusion, improving EBF rates will, therefore, require improved access to information on EBF targeting low socio-economically disadvantaged and older mothers. In addition, emphasis on strengthening the ongoing EBF counseling already within the health system is required.
This cross-sectional study was carried out at the Edward Francis Small Teaching Hospital (EFSTH) polyclinic in Banjul, The Gambia from 16th December 2015 to 8th February 2016. A wide range of services is offered by the clinic that includes but not limited to maternal and child health, family planning, immunization, health promotion and general out-patient care. For this study, only mothers attending antenatal and child health services with pregnancies over four weeks of gestation and postnatal mothers with children less than one year of age were included. Mothers with pregnancy complications or other comorbidities and children presenting specific feeding problems (cleft palate or lip and severely ill) were not legible to participate. Recruitment and data collection was done by student nurses trained on administering the questionnaire in major local languages. The clinic was visited on each clinic day and while mothers were waiting to receive care, they were approached to participate in the study. All participants arriving at the clinic between 08.30 am (clinic start) to 14.00 (clinic end) were contacted to participate in a successive manner. Those that consented to participate and were eligible were taken to a secluded area and after undergoing the consenting process, they were administered a face-to-face questionnaire in their local language if the participant does not understand the English language. All participants provided written informed consent. The questionnaire which was adopted from previous instruments [22, 29, 30] was tested for reliability using test-retest while validity was established by breastfeeding experts. Following pilot testing in 20 antenatal and postnatal mothers, it was revised and then finalized for use. The instrument consisted of questions covering sociodemographic, reproductive health characteristics, knowledge on EBF, attitude towards EBF and intention to EBF (for antenatal mothers) or practice of EBF (for postnatal mothers). The Knowledge scale of the questionnaire consisted of 36 questions assessing mothers’ understanding and intellectual capacity to recall several aspects of EBF such as when to start breastfeeding after delivery, how often and for how long to breastfeed, benefits of the first milk (colostrum), how to improve breast milk supply, benefits of EBF for the first six months to the mother and child as well as the potential risks exposed to the child if not exclusively breastfed. Each correct response was accorded a point and no point in the case of a wrong response. Based on correctly answered questions, knowledge scores were obtained by summing up all correctly answered questions for each mother. A score of 29, which corresponds to the median, was used as the cut-off. Those scoring below the median were determined to have insufficient knowledge while scoring above or equal to the median was considered sufficient knowledge. The attitude scale of the questionnaire consisted of five questions that sought to determine the mother’s feeling on negative cosmetic effects of EBF, whether it is an indication of poverty, ease, and convenience of EBF and confidence in expressing breast milk for the infant. Each attitude item had two responses (true or false), and depending on the question structure a response indicating a desire to EBF was considered positive attitude and scored one point. All points were summed to form an attitude score. Women scoring less than three points were considered to have less positive attitude, while those scoring three points and above were considered to have a positive attitude. They were also asked if they have ever had any counseling on EBF, who in their family supports EBF and their source of knowledge on exclusive breastfeeding. EBF was defined as per WHO [1] and the intention to EBF was defined as the planned length of EBF measured using the infant feeding intention scale [30]. A successive sampling design was used to sample participants. The required number of subjects ‘n’ for the study was estimated at 345 using the formula n = (Z2 × P × Q)/D2 where ‘Z’ is the critical value and for a two-tail test, is equal to 1.96, ‘p’ is the estimated proportion of mothers who EBF their infants for six months in the study setting population, which was considered to be slightly less than the national rate based on the latest GDHS [15] and was estimated at 34%. ‘Q’ is the proportion of mothers that do not EBF their infants (1 − P) which is 66% and ‘D’ is the accepted margin of error (0.05). A 2% contingency was added to account for any incomplete data making up a total of 352. An equal proportion of antenatal and postnatal women were recruited. About 5% of the sampled participants were dropped due to incomplete data and language barrier, leaving a final sample of 334 for final analysis. Data were analyzed using SPSS software for windows 20.0 (SPSS, Chicago, IL, USA). Baseline characteristics were summarized as mean and standard deviation for continuous variables and frequency and percentages for categorical variables. Unconditional binary logistic regression models were used to estimate the odds ratio (OR) and their 95% confidence intervals (Cls) to assess the univariate association between predictors and knowledge of EBF as well as the intention to or practice of EBF. Adjusted odds ratios (aOR) and 95% Cls were estimated in a multivariate logistic regression model that included only variables significant in the univariate model. A p < 0.05 was considered to be statistically significant.
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