Knowledge, Practices and Factors Affecting Exclusive Breastfeeding among Lactating Mothers with Babies aged 6 months to 1 year attending Magomeni Reproductive and Child Health Clinic, Kinondoni, Dar es Salaam: Descriptive Cross Sectional Study

Background: Exclusive Breastfeeding dened as the infant has to receive only breast milk from his/her mother with the exception of other kinds of food for six months. Exclusive Breastfeeding helps to prevent diseases to infants and it reduces risk of ovarian cancer to mother. Methodology: Descriptive cross sectional study was conducted among 124 lactating mothers with infants aged 6 months to one year attending Magomeni RCH Clinic in Kinondoni, Dar es Salaam. Simple random sampling procedure was used to obtain 124 lactating mothers. Data was collected from mothers who agreed to participate and signed the consent form by the use of close ended Swahili version questionnaire on assessing knowledge, practices and factors affecting Exclusive Breastfeeding among Lactating Mothers with Babies aged 6 months to 1 year attending Magomeni Reproductive and Child Health Clinic in Kinondoni district, Dar es Salaam. Result: About 74 (59.7%) respondents had high knowledge on EBF and 92 (74.2%) respondents initiated breastfeeding within one hour after delivery while 77 (62.1%) practiced exclusive breastfeeding. Findings show that 64(51.6%) respondents denied that exclusive breastfeeding causes loss of shape of their breasts while 48 (38.7%) respondents accepted that exclusive breastfeeding causes loss of shape of their breasts. Only 12 (9.7%) respondents didn’t know if EBF causes loss of breasts shape or not. Moreover, 19 (15.3%) respondents had physical diculties/problems like cracking of nipples, inadequate milk, while 105(84.7%) didn’t get any physical dicult. Therefore there is signicant association between mothers belief of losing shapes of their breasts and EBF (p=0.05). Physical diculties/problems to lactating mothers study is signicantly associated with EBF (p = 0.000). Conclusion: The overall knowledge among the lactating mothers with babies aged six months to one year was high and had good exclusive breast feeding practice. Although majority of the respondents are knowledgeable about EBF, the results show a gap between knowledge and actual practice within six months which is a recommended duration for Exclusive Breast feeding.


Background
Exclusive Breastfeeding (EBF) has been de ned by the World Health Organization "WHO" as the infant has to receive only breast milk from his/her mother, or expressed breast milk, and no other liquids or solids, with the exception of drops or syrups consisting of vitamins, mineral supplements or medicine (1).
WHO recommends EBF for the rst six months of life, and there after continue breastfeeding for two years or longer along with complementary food (1). Bene ts of exclusive breastfeeding to the child include a decrease incidence and severity of many infectious diseases such as diarrhea, otitis media, urinary tract and respiratory tract infections and obesity (2). EBF also increases the maternal-infant bonding. In the long run, it may decrease the risk of breast and ovarian cancers, and osteoporosis in the mother (3).
Despite the bene ts of exclusive breastfeeding, the prevalence and duration globally is much far from the recommended universal coverage. Globally infants under 6 month of age, only 36% are exclusively breastfed. It rarely exceeds 30% in most regions of the developing world given their greater risk of infection and its consequences. The rate of exclusive breast feeding is low in Africa, especially in west and central Africa which is only 20%. Over the past 10 to 15 years exclusive breastfeeding rates have increased in the developing world as a whole and in many countries of Africa and Asia in particular; however, the progress has been modest, from 33% in 1995 to 37 % in 2008 in the developing world (4).
In Tanzania data from TDHS surveys indicate that exclusive breastfeeding among children under age 6 months has been steadily increasing, from 26% in 1991-92, to 41% in 2004-05, to 50% in 2010 and 59% in 2015-16 (5). Exclusive breastfeeding is regarded to be important for infants' survival. Indeed, of the 6.9 million under ve children who were reported dead globally in 2011, an estimated 1 million lives could have been saved by simple and accessible practices such as exclusive breastfeeding. About 60% of under-ve mortality is caused by malnutrition either directly or indirectly, whereby more than 2/3 of the deaths are associated with inappropriate breastfeeding practices during infancy (6). Breastfeeding practice can save many as 1.5 million infants' lives every year as it provides signi cant protection against diseases (7).
Efforts have been made by the Government, Donors, NGO and other stakeholders to protect, support and promote exclusive breastfeeding like raising public awareness through mass medias but still there is an inadequate practice of exclusive breastfeeding, More than half (51%)of infants are breastfed within one hour after birth. Fifty-nine (59) percent of infants below age 6 months are exclusively breastfed (5). The 2015-16 Tanzania Demographic and Health Survey and Malaria Indicator Survey (5), indicated there are challenging factors that cause inadequate exclusive breast feeding practices.
Besides, the effort made by Ministry of Health Community Development Gender, Elderly and Children, still there is a challenge of inadequate exclusive breastfeeding practice in Tanzania. In Tanzania, 16 mothers out of 100 (16%) initiate breastfeeding within one hour after delivery while 84% of mothers initiate breastfeeding within 24 hours post-delivery (8). Despite the fact that majority of mothers (92%) gave colostrum to their infants, half of them did not know its bene ts, 8% discarded colostrum demanding that it was not good for baby's health and they offered other uids especially water before milk was secreted, Furthermore, nearly all infants (98%) were breastfed but only 70% were being breastfed on demand while no child above 4 months was exclusively breastfed (8). Good achievement has been attained in Tanzania in case of breastfeeding. Despite the mothers (98%) breastfeed their babies, good breastfeeding practice is not yet attained. Only 16% of mothers initiate breastfeeding within one hour of birth, half of them do not know the bene ts of colostrum (5). This study aimed to assess on knowledge, practices and factors affecting Exclusive Breastfeeding among Lactating Mothers with Babies aged 6 months to 1 year attending Magomeni Reproductive and Child Health Clinic in Kinondoni district, Dar es Salaam.

Study design and Setting
The study used descriptive cross sectional design. According to (9) descriptive cross-sectional design is de ned as the design that involves the collection of data at one point in time. This study design was used because it is economical and easy to manage within the study period (10). This study was conducted at Magomeni RCH clinic located at Magomeni Health Centre in Kinondoni municipality. Kinondoni is one of the ve municipalities within Dar es Salaam region; others are Ilala, Temeke, Ubungo and Kigamboni.
Magomeni RCH clinic is the one among RCH clinics which provide services like antenatal services, vaccination, family planning services, postnatal services and children treatments. Researcher chose this site because there is high number of lactating mothers who attend in this clinic approximately 40-50 mothers per day (20) Study population Study population is de ned as the entire set of individuals or objects having some common characteristic (9). The study population was lactating mothers with children aged 6 months to 1 years attending Magomeni RCH clinic in Kinondoni Municipality. Researcher chose this population because these lactating mothers have already completed rst six months of exclusive breastfeeding. Therefore they provided adequate information concerning their experience during exclusive breastfeeding.

Data collection instruments
The study used self-administered structured questionnaire in Kiswahili language translated from original English version and retranslated to English in order to check for consistency. The questionnaire was developed and modi ed to meet the objective of assessing knowledge, practices and factors affecting Exclusive Breastfeeding among Lactating Mothers. The questionnaire was divided into four parts; rst part was about social-demographic characteristics with a total of ve questions, second part was assessment of knowledge with a total of ve questions, third part was assessment of practices with a total of three questions and fourth part was factors affecting exclusive breastfeeding with a total of ve questions.
A scoring system was established whereas a correct answer was scored one mark and the summation of total score was computed to each participant. For the participant(s) who scored knowledge below 50% were considered to have low knowledge, 50-80% was considered to have moderate knowledge and 81-100% was considered to have high knowledge. Therefore the study questionnaire collected the intended data from lactating mothers with children aged 6 months to 1year.

Sample size and Sampling Technique
This is the total number of study participants participating in a study (9). The sample size required was calculated by using statistical Formulae (12) Where, n=sample size, Z=Z value for con dence level and P=expected proportion or prevalence and d= con dence interval and Z² = 95% of con dence level and equals 1.96 and P =expected prevalence of exclusive breastfeeding was 92%. It was obtained from the study titled; factors affecting exclusive breastfeeding among post-natal mothers in Kinondoni municipality, Dar es Salaam where they found prevalence of people having knowledge is 92% (11) and d² = is the level of precision or sampling error and equals 5% (0.05) So the sample size was determined as; and researcher needed 10% of this value (113) due to the reasons that there is possibility of nonresponses from participants. Therefore sample size was 124 lactating mothers having children with age of 6 months to one year.
Sampling is the process of selecting a proportion of the population to represent the entire population (9). The study used simple random sampling method; simple random sampling is de ned as sampling whereby a sampling frame is created by enumerating all members of population, and then selecting a sample from the sampling frame through completely random procedures (9). In this study the sample was obtained by simple random sampling by employing lottery method, whereby, pieces numbered either number 1 or 2 were given to the participants, then the participants were asked about the paper number each one has picked those with the paper numbered 1 were selected to participate in the study. This were done repeatedly until the required sample size of lactating mothers with children aged 6 months to 1 year were attained.

Data Collection Methods
Researcher used self-administered structured questionnaire for data collection, whereby researcher distributed them to participants in separate rooms and ll questionnaire to ensure privacy. Before administering the questionnaire, verbal informed consent was obtained from participants. Moreover, code numbers was used instead of names to ensure con dentiality. The researcher was directly involved in data collection process with a research assistant for data collection. Pilot testing was done at Mwenge RCH whereby, 40 lactating mothers with children aged 6 months to 1 year were recruited to assess understanding of the questionnaire in gathering intended information and the queries was identi ed and corrected to avoid methodological errors.

Data analysis
The data was entered in computer, cleaned and coded then analyzed using statistical package for social sciences (SPSS) software version 23.0. From all participants concern with social-demographic characteristics, knowledge and practices towards exclusive breastfeeding and also facilitators and barriers of exclusive breastfeeding will be entered, cleaned, coded, analyzed and nally summarized using descriptive statistics of frequencies and percentages and tables. Also chi square test was used to determine association between factors affecting EBF and EBF practices. Cross tabulation used to nd out the factors associated to exclusive breast feeding. Independent variables shown signi cant associated with (p ≤0.05) to the dependent variable (EBF) and data tested by using Chi-square.

Results
Demographic Characteristics of the Participants The age of the women was between 15 to 49 years. Findings revealed that, 39 (31.5%) age group ranging between 25-29 years were the most dominant group involved in the study compared to other age groups.
Most were married 87 (70.2%), 87 (70.2%) study participants had one to two children. Also, ndings showed that, 63 (50.8%) had primary school level of education and 56 (45.2%) were house wife. The demographic characteristics are further shown on the table 1.  The overall knowledge of respondents was graded as low, medium and high knowledge. Therefore, the study revealed that, majority of respondents 74(59.7%) had high knowledge compared to other levels like, 44 (35.5%) moderate knowledge and 6 (4.8%) had low knowledge.

Association between Factors affecting EBF and Exclusive Breastfeeding Practice
Concerning partners or spouses support to lactating mothers study revealed that there is signi cant association between exclusive breastfeeding and support of lactating mothers from their partners or spouses (p = 0.000). Also, study ndings showed that there is signi cant association between health education about EBF and exclusive breastfeeding where p-value was 0.019 and there is signi cant association between health educations about baby positioning during breastfeeding and exclusive breastfeeding (p = 0.025). Other information is condensed in table 6.  Majority of the respondents 97 (78.2%) know the meaning of exclusive breastfeeding which is giving baby only breast milk without any food or drink with exception of prescribed medicines. This nding was slightly lower than study results done in Zanzibar at mnazi Mmoja hospital whereas (82.2%) respondents knew the correct de nition of exclusive breastfeeding (13). Also, ndings show that 118 (95.2%) respondents knew the exact recommended duration of exclusive breastfeeding which is higher than the results of study which was done in Zanzibar at Mnazi Mmoja clinic where (77.8%) respondents knew the recommended duration for exclusive breastfeeding (13).
It was found that (74.2%) respondents initiated breastfeeding within one hour after birth. This nding is different from the results which were found by TDHS-MIS (5). This practice of initial breastfeeding within rst hour has in uence toward exclusive breastfeeding. But only 62.1% of infants were exclusively breastfed which is slightly higher than 59% found by TDHS-MIS, (5).
According to the study maternal knowledge about exclusive breast feeding, partners/spouse support, health education from health care providers about exclusive breastfeeding and health education about baby positioning during breastfeeding are the four factors which had signi cant association with exclusive breastfeeding practice. This study revealed maternal knowledge about exclusive breastfeeding has signi cantly associated with their practice (p-value = 0.001).This means that women with high and moderate knowledge level do practice breastfeeding exclusively. These ndings are nearly similar with the results of the study which was done in Ambo Woreda West shoa zone Oromia region, Ethiopia where EBF practice was more common among knowledgeable mothers ( p = 0.003) (14).
This study also revealed that high percent of women got support from their partners/spouses 114 (91.9%) during EBF and also support from partners/spouses has signi cantly associated with their practice (p-value =0.000). This is supported by the study done in united states where they found that role of father was the one of the strongest in uences on the initiation and duration of exclusive breastfeeding where 75% of mothers in the study identi ed father as the important decision to breastfeed exclusively .
Also this study results are supported by results from another study done in Australia whereas husbands support had a signi cant association with EBF practice. A mother who was supported by her husband's practiced EBF better than those who were not supported (15).
This study revealed that most of mothers who got health education about exclusive breastfeeding are the one who practiced more exclusive breastfeeding (p = 0.019). This is supported by the study conducted at Arba Minch Zuria in Ethiopia in which ndings from in-depth interviews indicated mothers' knowledge of optimal breastfeeding is due to an exposure to health education given by health extension workers (16).
This study revealed that there is signi cant relationship between health education about baby positioning and exclusive breastfeeding (p-value =0.025). This results are not so new because ndings from a study which was done at St. Michael's Hospital in Bristol (UK) showed that mothers with high scores had good baby positioning technique and breastfed exclusively for six months (p = 0.02 (17). This would probably be due to that many health facilities in Tanzania have breastfeeding guidelines where health workers educate and demonstrate breastfeeding practices as well as issues of attachment and how to hold the baby during breastfeeding Findings uncovered that mothers' fear of losing shape of their breasts and physical di culties/problems like cracking nipple, lack of milk secretion and mothers' illness hinder exclusive breastfeeding. Results show that there is signi cant relationship between mothers losing shape of their breasts and exclusive breastfeeding where (p = 0.05). This is in line with the study done in Ayeyarwaddy Region in Myanmar whereby by lactating mothers reported that, they are worried that exclusive breastfeeding would make them less attractive so they can feed the baby formula milk also these women take injections to stop producing breast milk (18). This study con rmed that mothers who have had physical problems/di culties during rst 6 months were less likely to have exclusively breastfed their babies than mothers who didn't encounter problems (p = 0.000). This is supported by study done in SMBD-Jewish General Hospital, Montreal, Quebec, Canada where by women who have had pathological problems during the rst 6 months were 86% less likely to have exclusively breastfed their infants than women who did not encounter such problems (19) This study revealed that there is no signi cant association between occupation status of the lactating mothers and exclusive breastfeeding practice (p = 0.355). This is different from the study done in in Motta town, East Gojjam zone, Amhara Regional State, Ethiopia where unemployed mothers practiced EBF better than employed mothers (14) . In another study done in El Sabbah Hospital Juba-South Sudan mothers' occupation was also found to be insigni cantly associated with EBF (10).
Study also revealed that there is no signi cant association between number of children mothers have and exclusive breastfeeding practice (p = 0.678). This is contrast to the study which done in El Sabbah Hospital Juba-South Sudan where mother with less children tend to exclusively breastfed more than the ones with many children (10). This can be because they are not driven away from their babies by the increasing responsibilities of the older ones. Also, study revealed that there is no signi cant association between marital status of the mothers and exclusive breastfeeding practice (p = 0.168). This is in line with the study done in El Sabbah Hospital Juba-South Sudan where maternal marital status was not signi cantly associated with EBF (10). Extended family can be cause, because even single mother can still get support from the relatives.
Study revealed that there is no signi cant association between education level of the mothers and exclusive breastfeeding practice (p = 0.349). This doesn't line up with the results from the study which was done in Aminu Kano Teaching Hospital Nigeria where results show that there is association between educational attainment of lactating mothers and EBF practice (20). Study found that there is no signi cant association between age group of the mothers and exclusive breastfeeding practice (p = 0.190). This is similar to the results from the study which was done at El Sabbah Hospital Juba-South Sudan where age of the mother was not signi cantly associated with EBF (10). This can probably be due to the fact that exclusive breastfeeding depends on mothers' willingness to breastfeed which is in uenced by family support.

Limitations
Recall bias was a potential limitation due to the fact that information on EBF based on recall since birth and some lactating mothers might not remember when they speci cally introduced other liquids or solids. To minimize the recall bias above, the researcher used check and balance technique where by a researcher was repeating asking questions in a different way which requires the same answer as from the previous asked question so as to see the consistency and validity of the responses.

Conclusion
Most of mothers had high knowledge about exclusive breastfeeding. Few mothers practice exclusive breastfeeding although most of them had high knowledge. Therefore there is a need to strengthen partners/spouses support; health workers counseling especially couple counseling, management of mothers' physical di culties like cracked nipples through proper attachments, health workers training mothers on baby positioning.

Declarations
Ethical approve and consent to participate The ethical clearance approval was obtained from the District Medical O cer from Kinondoni municipality, Medical O cer In charge of Magomeni Health Center in Kinondoni Municipality. Then the overall consent to participate to the community was provided by the Kinondoni municipality. Also both written and oral informed consent to lactating mothers with children aged 6 months to 1 years attending Magomeni RCH clinic in Kinondoni Municipality were given before starting data collection so as to ensure con dentiality and autonomy of the respondents, no names of the respondents were involved in the questionnaires.

Consent for publication
Not applicable Availability of data and materials The datasets used are available from the corresponding author on reasonable request.