The study findings showed that health care workers in this study had good knowledge of EBF (80%). While other researchers use only the WHO definition to assess knowledge on EBF, multiple questions were used to evaluate the level of knowledge on EBF in this study, and still the theoretical knowledge was high (14, 22). Similar results of high knowledge were found in Ibadan, Nigeria where 90% of health workers had good knowledge of duration for EBF including advantages of breastfeeding. (23). Okolo & Ogbonna (2002) in Nigeria assessed the level of knowledge, attitude and practice among health workers on BFHI practices and found that only 20.8% of health workers were aware of the need for initiating breastfeeding within 30 minutes of birth while 92% of health providers in our study knew the correct time of BF initiation (22).
In this study health care workers who have attended in-service training on breastfeeding had increased odds to have good knowledge of EBF as the non attendee group. This is similar to studies in Kenya and Nigeria which showed improvement in breastfeeding knowledge among health workers after training on breastfeeding (22, 24). During the survey it was noted that, the two districts involved in this study were among seven districts in Tanzania which received intensive support from UNICEF for implementation of breastfeeding promotion activities including other programmes on child survival and development hence, the situation may differ from other districts which did not receive such support.
Nearly 4 out of 10 health care workers believed that babies who are exclusively breastfed do not get enough water from the breast milk and others felt that babies should be introduced to fruit juice and light porridge at the age of four months. Giving babies anything other than breast milk in the first six months interferes with demand suckling and increases the risk of both diarrhoea and respiratory infections (5, 7, 21, 25). These beliefs might have negative impact on EBF. Studies have observed that, in some societies, health workers recommendations and information are highly valued by mothers and they often take their recommendations as the final word (9, 14). If health care gives mixed and incorrect messages it will confuse many women attending the RCH services as health care workers are believed to be the primary source of accurate and helpful information to mothers regarding most issues in maternal and child health including EBF (9). It is also important to note that 74% of health subjects in this study reported to have received information on breastfeeding and EBF from training. These identified gaps need to be rectified or addressed during pre and in-service training of providers in breastfeeding.
In this study, one in four health care workers felt that HIV-positive women need to be advised not to breastfeed. This is contrary to the national guidelines which states that all the HIV positive women should exclusive breastfeed their infants for the first six months, and advised otherwise only if alternative feeding is affordable, available, feasible, safe and sustainable (26). With most developing countries moving to option B + i.e. treating every HIV-positive pregnant and breastfeeding woman with triple antiretroviral therapy, the chance of breast milk transmission is low. Thus WHO in 2010 and Tanzania in 2013 have changed the advice and currently HIV-positive women also should exclusively breastfeed their infant for six months, and can continue to breastfeed up to 12 months of age (27, 28). These rapid change of recommendations in infant feeding among HIV-positive women needs to be rapidly disseminated to providers on the ground, as studies have observed it may take years for providers to became aware that guidelines have changed (29).
The vast majority of health care providers in this study had poor skills despite having good knowledge on EBF. Two thirds of the respondents indicated they had taught and supported mothers on proper positioning and attachment of the baby to the breast but surprisingly, only one in ten could list correct steps for good positioning and attachment to demonstrate the quality of practical skills to support mothers on EBF. Good positioning and attachment are two most important skills every lactating mother needs to be taught to comfortably establish EBF, maintain breastfeeding and prevent development of breast problems like engorgement and cracked nipples (21). Breast problems are among the factors negatively influencing duration of EBF (30).
Poor skills in supporting breastfeeding have also been observed in Nigeria where, only 5.2% of health workers interviewed were able to demonstrate correct positioning of the baby for breastfeeding (22). This calls for the need to assess the current training on breastfeeding for health care providers in the country and change the curriculum to emphasize on development of clinical/practical skills (24). Competence based training using mannequins and videos which have been shown to improve clinical skills among health care workers in performing signal functions of emergency obstetric care should be applied to breastfeeding trainings (31). Only one health facility was observed to give practical demonstrations to postnatal women on how to position and attach the baby to establish breastfeeding within the 24 hours after delivery. It might be that providers are not teaching practical skills due to lack of skills themselves. Or it may be due to the fact in many facilities there is severe shortage of human resources resulting into low quality of care (32). This is a missed opportunity given that 86% and 96% of women in Kilimanjaro deliver at health facilities with skilled providers in the year 2010 and 2016 respectively (4, 11). Studies have shown a correlation between women’s intentions to EBF, confidence or skills in breastfeeding and duration of exclusive breastfeeding (18–20, 24). The need to improve breastfeeding practices as one of the strategies to improve neonatal and child health and attain the sustainable development goal 3 of promoting wellbeing (33). One of the things to target is improving health provider’s skills in supporting breastfeeding and improving their knowledge and skills in broader topics pertaining to reproductive, maternal, newborn and child health so as to offer holistic and integrated care.
The study has some limitations. Information on practices of health care providers on skills in supporting women was obtained from interviews, and observation of individual providers was not performed. To get more information, future studies should use real time clients or mannequins to assess the skills of providers. Also observations conducted at postnatal wards on supportive practices to initiate and maintain breastfeeding took a day at each site. We may have thus underreported facilities were not performing the practices e.g. management of breast conditions (cracked nipples), but perhaps in practice they sometimes do offer support.