Infants are at risk of negative health consequences associated with non-exclusive breastfeeding practice (EBF). Globally, 60% of the 10.9 million infant deaths annually occur due to inappropriate or suboptimal infant feeding practices and infectious disease and two-thirds of these deaths are attributable to suboptimal breastfeeding practices [1]. Suboptimal breastfeeding is responsible for 1.45 million deaths per year that is 4,000 deaths per day, 165 deaths per hour, or 3 deaths per minute [2]. This is because nearly 60% of the world’s infants are missing out on the recommended six months of EBF [3], while about 40% of infants 0–6 months old are exclusively breastfed [4]. The consequences of inappropriate infant feeding or non-EBF practice results to infection from gastro-intestinal diseases such as necrotizing enterocolitis (NEC), the occurrence of otitis media, and of several other bacterial infections such as meningitis, bacteremia, lower respiratory infections and botulism, infant mortality and morbidity [5-6]. On the other hand, exclusively breastfed children perform better on intelligence tests, will be less likely to be overweight or obese, will be less prone to diabetes later in life and have reduced risk of breast and ovarian cancers in women [7].
Nigeria lost 103,742 children to the deficit in breastfeeding in 2017 despite initiative programs to protect, promote and support EBF in the country and its benefits to infants, mothers, families and society [8]. Moreover, low breastfeeding rates continue to be evident in Nigeria despite widespread information regarding the benefits. According to a national survey, only 27% of children in the country were exclusively breastfed by their mothers, leaving a deficit of 73% that was denied the right [9]. This situation could be traceable to socio-cultural factors. Thus to ensure decline in infant’s mortality and morbidity due to non-practice of EBF, research on the combined influence of major socio-cultural factors such as education and ethnicity on EBF practice in Nigeria, especially in the rural-urban comparative context is important because the practice rate of EBF differed among ethnic groups and among urban and rural dwellers in Nigeria.
Studies have shown that place of residence has a strong influence on other factors which influence decisions around EBF practice in both developed and developing countries. Among Chinese women, agriculture related occupations were positively associated with early initiation of breastfeeding, current breastfeeding, EBF and predominant breastfeeding among both local and migrant populations [10]. In Dhaka Bangladesh, the prevalence of EBF was lower (36%) than the national prevalence (55%) among urban slum dwelling mothers. Moreover, child gender, maternal age, education and household income, infant’s age were negatively associated with EBF [11]. In India, there were wide variations in regional prevalence and determinants of EBF, where Southern India had the highest EBF prevalence (79.2%) and the North-East reported the lowest (68.0%), which decreased with infant age, dropping faster in the South compared to the North-East region at 5 months. Higher birth order was a common factor associated with non-EBF across all regions of India, while maternal education is a key modifiable determinant of non-EBF [12]. Moreover, being employed, mother’s poor knowledge on what she meant by EBF, mother’s poor attitudes towards EBF, unsupported environment in public places, cultural practices discouraged EBF and were independently associated with early cessation of exclusive breastfeeding in Sri Lanka [13]. In Taiwan, education level, primiparity, perceived low milk quantity, and return to work are associated with premature cessation of EBF in Taiwan [14].
In Ethiopia, informally employed mothers and those with six or more family size were more likely to exclusively breastfeed their babies [15]. While attending formal education, low birth order and lack of knowledge about EBF were found to be negatively associated with EBF practice in rural communities of Hula District, Southern Ethiopia [16]. Among rural mothers in Southern Ghana, maternal age, type of occupation, household size and district of residence are determinants of 6 months EBF [17]. In Malawi, age of children was associated with increased odds of EBF, with children aged 3–5 months being less likely to be exclusively breastfed [18]. In Somaliland, EBF practice was associated with having female child, lack of formal education, household monthly income 100$-200$, lack of husband’s support and mothers who were not counseled on breastfeeding during antenatal care [19].
Furthermore, variations existed between ethnic groups globally and in Nigeria on the practice of EBF. For instance, study in China revealed that differences were found in the rates of exclusive breastfeeding among the ethnic groups for children in the first 1, 2, 3, 4, 5 and 6 months of life [20]. In addition, traditional beliefs, myths and misconceptions about EBF and lack of support from husband and family were found to be barriers for proper EBF practice in Aysaita woreda, Afar, Ethiopia [21]. Another study showed that after delivery, the mother has to rest and clean up and some rituals and prayers have to be performed before breast feeding commences in among different ethnic groups in Sub-Sahara Africa [22]. In Nigeria, it has been argued that the reasons adduced for delay initiation of breastfeeding among the Yoruba of South West Nigeria was colostrums, thus supporting the general perception in the study area that in the first three days, the mother’s milk is not pure and therefore could harm the infant [23]. In addition, while awaiting the establishment of the clean milk, mothers gave prelacteals in form of boiled water, honey and animal milks. Among the Yoruba in Ibadan, it was reported that mothers believed that feeding infant with water, infant formula/cereal gruels and herbal teas within the first six months of life is necessary stride for child survival [24]. Among the Ibos in South East Nigeria, literature revealed that the reason for low uptake of EBF was because some mothers believed that breast milk is good enough for the baby during the EBF period, while others believe colostrums is harmful to baby, dirty, infected milk and should not be given to the baby [25]. Furthermore, among the Hausa of Adamawa in North East Nigeria, it was shown that the problems that inhibits or reduce the practice of EBF include the assumption that colostrums is stale milk, breast milk lacks sufficient nutrients, expressed breast milk is contaminated milk, thought that food supplements were ideal for infants [26].
In Nigeria, different studies have been carried out on the prevalence and other factors of EBF. For instance, a study revealed that 76.4% of mothers practiced EBF for a period of 4-6months, 38.2% initiated breastfeeding within 30 minutes and 33.2% within an hour, while few breastfed on demand [25]. Also, age, educational attainment, EBF knowledge and sources of information about EBF are to be significant predictor of good intention to practice EBF [27]. In addition, rural mothers with low socioeconomic status, early initiation of breastfeeding and delivery assistance have been shown to be more likely to practice EBF [28]. Geopolitical variability in breastfeeding patterns exist also in Nigeria with relatively lower prevalence in the less urbanized areas of Nigeria [29]. Maternal education had also been identified as relevant and related to knowledge of EBF. In this context, mothers with lower education are more likely to breastfeed their infants exclusively than those with higher education [30], while a study revealed no significant relationship between level of education and the practice of EBF [31]. Another study reported that mothers with higher level of education were more likely to breastfeed exclusively for 6months [25], while [22] reported that mothers with at least primary education engaged in early initiation of breastfeeding compared to mothers with no schooling, while those with no formal education had higher odds of not practicing EBF compared to those with secondary education or higher. Moreover, literature has shown that level of education of mothers had positive associated with the practice of EBF [32].
From the foregoing, it is obvious that EBF is very much influenced by ethnic practices and levels of education. However, there is dearth of studies on the combined influences of ethnicity and education on EBF in Nigeria, even as a nationally representative rural-urban comparison of prevalence and factors of EBF have been carried out in the country. Thus, this study examines the association between ethnicity and education with EBF practice in the context of rural-urban residence on a nationally representative population of Nigeria.