The Knowledge and Attitude of Lactating Mothers towards Exclusive Breastfeeding in Juba, South Sudan

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University/College: University of Juba College of Medicine (Department of Community Medicine)

Title: The Knowledge and Attitude of Lactating Mothers towards Exclusive Breastfeeding in Juba, South Sudan

Submitted By:  Wani Bosco Fabiano Ayire, Chol Mabil David Ajang, Wahib Natale Daniel, John Mawich Nangdor, Joshua Jockjio Thor Machar, Ruai Koang Mut

Purpose:  A Thesis Submitted In Partial Fulfilment For The Award of Bachelor of Medicine and Bachelor of Surgery (MBBS)

Date of Submission: June 30, 2014



The knowledge and attitude of mothers towards exclusive breastfeeding was studied between December 2013 and June 2014 in Juba, Republic of South Sudan.

One hundred and twenty-three (123) lactating mothers (with infants less than or equal to six months of age) were interviewed using self-administered well structured questionnaires, for literate mothers and verbal interpretation of questionnaires to illiterate mothers at Al-Sabbah Children’s Hospital Juba by trained Health personnel.

Scoring of the responses to questions was done and the data were analyzed using Statistical Package for Social Sciences (SPSS) version 16.0.

Our results have confirmed that some factors such as age, religion, occupation, marital status, educational status, health status, attendance at antenatal clinics (ANC), other dependents at home and diverse opinions have affected the knowledge and attitudes of mothers towards EBF. Better scores correlated significantly with maternal literacy, younger maternal age and ANC attendance. As such there is a need for programmes which support and encourage EBF practices at all health care levels.

The knowledge of the mothers was in adequate in areas of time of initiation of EBF (62.6%), duration of EBF (67.5%), positive attitude towards EBF (85.4%).We therefore, concluded that knowledge and attitude of mothers to EBF is influenced by some demographic and socio-cultural factors.


Background of the Study  

Breastfeeding is the feeding of an infant or young child with breast milk directly from the mother’s breast (i.e. via lactation) rather than using infant formula. It is an important public health strategy for improving infant and child morbidity and mortality, as well as improving maternal morbidity and helping to control health care costs (1).

The World Health Organization (WHO) and United Nations Children’s Fund (UNICEF) recommend that every infant should be exclusively breastfed for the first six months of life, with breastfeeding continuing for up to two years of age or longer. Exclusive breastfeeding (EBF) for the first 6 months of life improves the growth, health and survival status of newborns (2) and EBF is one of the most natural and best forms of preventive medicine. EBF plays a pivotal role in determining the optimal health and development of infants, and is associated with a decreased risk of early life threatening diseases and conditions, including otitis media, respiratory tract infection, diarrhoea and early childhood obesity (3).

Joshua Jockjio Thor is one of the researchers.

Joshua Jockjio Thor is one of the researchers.

It is estimated that sub-optimal breastfeeding, especially non-exclusive breastfeeding in the first 6 months of life, results in 1.4 million deaths and 10% of the disease burden in children younger than 5 years of age (4). EBF reduces infant mortality rates by up to 13% in low-income countries (5).

The government of some African countries like Nigeria and Ghana have established the Baby-Friendly Hospital Initiative (BFHI) with the aim of providing mothers and their infants a supportive environment for breastfeeding and to promote appropriate breastfeeding practices, thus helping to reduce infant morbidity and mortality rates (6)

Numerous variables may influence breastfeeding such as race, politics, maternal age, maternal employment, level of education of parents, socio-economic status, insufficient milk supply, infant health problems, maternal obesity, smoking, parity, method of delivery, maternal interest and other related factors

Some researchers have proposed that lack of suitable facilities outside of the home, inconveniences; conflicts at work, family pressure and ignorance adversely affect the willingness of women to practice EBF (7). The need to return to work has also been implicated as a factor interfering with EBF (8).

A more detailed understanding of the attitude of mothers to EBF and their knowledge of the importance of breastfeeding in South Sudan is needed to develop effective interventions to improve the rates of EBF and thus reduce infant mortality. The goal of the proposed study is to investigate the attitude of mothers to exclusive breastfeeding (EBF) and their knowledge of the significance of exclusive breastfeeding in Juba city, Republic of South Sudan.

Scope of the Problem  

Historically, abandonment of breastfeeding began in higher socioeconomic level followed by a decrease in lower socioeconomic levels. As the trend was reversed, women in the upper socioeconomic levels were the first to show an increased incidence of breast feeding followed by progression down class line. A significant boost to breastfeeding came from the American Academy of Pediatrics (AAP), which in 1978 recommended that all Physicians encourage mothers to breast their babies.

Data suggest that infant mortality in developing countries is 5-10 times higher among children who have not been breastfed or who have been breastfed for less than six months. It is estimated that some optimal breastfeeding especially non-exclusive breastfeeding in the first six months of live results in 1.4 Million deaths and 10% of disease burden in children younger than five years (9).

Wani Bosco Fabiano (a research team member)

Wani Bosco Fabiano (a research team member)

In the Global Strategy for Infant and Young Child Feeding, according to WHO, two-thirds of under-five deaths that occur in infancy are mostly related to poor feeding practices. Globally, less than 40% of infants under six months of age are exclusively breastfed, despite the well documented benefits of breastfeeding (10). In developing countries only 38% of infants aged less than six months are exclusively breastfed (11).

According to the 2010 Sudan household survey only 45% of the babies in Southern Sudan are exclusively breastfed for the first six months of life.

On a press report released by UNCIEF on the breastfeeding week, 1-7 August 2013, they said most mothers in South Sudan do not breastfeed their children exclusively because of inadequate information on the importance of early initiation and EBF, inadequate support from families and communities, lack of counseling to new mothers on breastfeeding and heavy workload that keeps them away from their children for long hours. (12)

Statement of the Problem

One of the biggest threats to infant feeding is complacency. With competing priorities, disease specific funding, and interest in technologies, campaigns and products, the attention breastfeeding receives is very small, given the magnitude of the problem and the potential impact. Working mothers are kept away from their children by the schedules of their long working hours and hence have limited time to nurse their babies which in the long run create poor attitude towards breastfeeding.

Some women do not actually believe in the positive effects of EBF and this informs the continued feeding of their babies with other supplements like pap, echinacea and ready-made baby food. The concern of Doctors, health officials and organizations is ultimately on the decline in breastfeeding practices itself. Definitely, some socio-economic and cultural factors influence the extent and the duration of breastfeeding. Considering the importance of breastfeeding it is imperative to identify factors which can influence it, in addition to their knowledge and attitude toward EBF.

The commonest reasons for not breastfeeding exclusively include insufficient breast milk and the socio-cultural practice of giving water to babies because of the hot climate. Also there is a lot of misunderstanding about the adequacy of breast milk especially when the baby cries indicating incontinences mostly assumed by the mother to be hungry. Many of the nutrition-related diseases can be reduced in our society if mothers will subscribe to the idea of exclusive breastfeeding.

Knowledge and attitude are important factors for successful exclusive breastfeeding practice. The objective of this study is to assess knowledge and attitude towards exclusive breastfeeding among mothers attending Clinic at Al-Sabah Children Hospital Juba South Sudan. There were one hundred twenty three (123) mothers participating on this study. Multiple regressions will used to assess the influence of knowledge and attitude on exclusive breastfeeding.

Significance of the study to Public Health

Breastfeeding is associated with lower incidences of infant diarrhoea and respiratory disease, particularly in less developed countries. An ecological study on breastfeeding showed that more than half of all infant deaths from diarrheal disease and acute respiratory infections are preventable by EBF in infants aged 0-3 months and partial breastfeeding throughout the remainder of the infancy. Theoretical basis for this is the combination of the nutritional and immunomodulatory effects of human milk.

Chol Mabil Ajang (a research team member)

Chol Mabil Ajang (a research team member)

The significance of this research lies in the fact that it will contribute to the existing literature on the subject matter by providing an expository analysis of the pattern of exclusive breastfeeding in Juba South Sudan and identify the socio-economic factors that influence it. This would enhance policy formulation in the primary health care in the area of improving the practice of EBF among women.

To educate the public on the importance of exclusive breastfeeding which helps to reduce cases of early childhood illness and decrease health care costs. EBF also creates bonding.

This research on knowledge and attitude of lactating mothers towards exclusive breastfeeding will provide policy makers to come up with the necessary interventions to encourage exclusive breastfeeding in South Sudan based on the results of the research findings.

Justification for the Study

The practice or non-practice of EBF depends to a large extent on the knowledge on the importance of EBF and this knowledge influence their attitude towards EBF practice. A lot of women will not just breastfeed exclusively because they feel that breast milk is not adequate for their babies, whereas, breast milk is the only „baby food‟ that contains adequate nutritional contents necessary for the growing babies. Without it babies are exposed to several diseases and defects which can only be prevented naturally through breastfeeding exclusively.

Supplement to breast milk like pap and ready-made baby food tend to complicate the growing up process of babies since it exposes them to different diseases and risks during growth. Because there are several reasons why people do not practice EBF, and because of the problem associated with non-practice of EBF, it becomes necessary to carry out research on the study area. The study is being conducted to help address these issues.

Goals and objectives of Study

Goal: To ensure that every South Sudanese woman understand the importance of EBF for the optimal growth, survival and development of healthy infants.

General Objectives

  • To assess mothers‟ knowledge and attitude towards exclusive breastfeeding of infants in Juba.
  • To evaluate mothers‟ attitude towards exclusive breastfeeding (EBF).
  • To compare exclusive breastfeeding between working and non-working mothers.
  • To identify the major problems hindering EBF among the study group.
  • To identify the relationship between the age of mother and the attitude to breastfeeding of infants.
  • To find out the prevalence of EBF in Juba south Sudan.


Research Hypothesis

  • Educated mothers tend to exclusively breastfeed their infants more than the uneducated mothers.
  • Mothers who attend ANC are more likely to exclusively breastfeed compared to those who do not attend.
  • Elderly Mothers exclusively breastfeed Infants more than young breastfeeding mothers in Juba.


History of breastfeeding

In the early years of human race breastfeeding was common as it was for other mammals feeding their young. There was no alternative food for the infants and the mother along with other lactating females had no choice but to breastfeed the children.

The Egyptian , Greek and Roman empires saw women feeding their own children but later, the loyalty considered it something to be done by the lower cadre of the society as such wet nurses were employed to breastfeed their children.

In the late 15th century formula feeding first became popular as such many mothers substituted cow or goat milk for their own breast milk which was helpful especially to working mothers who did not have the time to breastfeed their child. This practice was later stopped when the problem with formula milk became noticeable.

Accordingly, there was a change in the late 1900s. Breastfeeding was becoming increasingly popular, partly because it reflected the back to nature movement of the time and partly because it was discovered to have unrecognized emotional and health benefits for baby and mothers (13)

Breast-milk composition

Breast milk contains all the nutrients that an infant needs in the first 6 months of life, including fat, carbohydrates, proteins, vitamins, minerals and water (14, 15). It is easily digested and efficiently used. Breast milk also contains bioactive factors that augment the infant’s immature immune system, providing protection against infection, and other factors that help digestion and absorption of nutrients.


Breast milk contains about 3.5 g of fat per 100 ml of milk, which provides about one half of the energy content of the milk. The fat is secreted in small droplets, and the amount increases as the feed progresses. As a result, the hindmilk secreted towards the end of a feed is rich in fat and looks creamy white, while the foremilk at the beginning of a feed contains less fat and looks somewhat bluish-grey in colour. Breast-milk fat contains long chain polyunsaturated fatty acids (docosahexaenoic acid or DHA, and arachidonic acid or ARA) that are not available in other milks. These fatty acids are important for the neurological development of a child. DHA and ARA are added to some varieties of infant formula, but this does not confer any advantage over breast milk, and may not be as effective as those in breast milk.


The main carbohydrate is the special milk sugar lactose, a disaccharide. Breast milk contains about 7 g lactose per 100 ml, which is more than in most other milks, and is another important source of energy.

Another kind of carbohydrate present in breast milk is oligosaccharides, or sugar chains, which provide important protection against infection.


Breast milk protein differs in both quantity and quality from animal milks, and it contains a balance of amino acids which makes it much more suitable for a baby. The concentration of protein in breast milk (0.9 g per 100 ml) is lower than in animal milks. The much higher protein in animal milks can overload the infant’s immature kidneys with waste nitrogen products. Breast milk contains less of the protein casein, and this casein in breast milk has a different molecular structure. It forms much softer, more easily- digested curds than that in other milks. Among the curds, or soluble proteins, human milk contains more alpha-lactalbumin; cow milk contains betalactoglobulin, which is absent from human milk and to which infants can become intolerant.

Vitamins and minerals

Breast milk normally contains sufficient vitamins for an infant, unless the mother herself is deficient. The exception is vitamin D. The infant needs exposure to sunlight to generate endogenous vitamin D – or, if this is not possible, a supplement. The minerals iron and zinc are present in relatively low concentration, but their bioavailability and absorption is high. Provided that maternal iron status is adequate, term infants are born with a store of iron to supply their needs; only infants born with low birth weight may need supplements before 6 months. Delaying clamping of the cord until pulsations have stopped (approximately 3 minutes) has been shown to improve infants‟ iron status during the first 6 months of life.

Anti-infective factors

Breast milk contains many factors that help to protect an infant against infection including:

  • immunoglobulin, principally secretory immunoglobulin A (sIgA), which coats the intestinal mucosa and prevents bacteria from entering the cells;
  • white blood cells which can kill micro-organisms;
  • curd proteins (lysozyme and lactoferrin) which can kill bacteria, viruses and fungi; and
  • oligosaccharides which prevent bacteria from attaching to mucosal surfaces.

The protection provided by these factors is uniquely valuable for an infant. First, they protect without causing the effects of inflammation, such as fever, which can be dangerous for a young infant. Second, sIgA contains antibodies formed in the mother’s body against the bacteria in her gut, and against infections that she has encountered, so they protect against bacteria that are particularly likely to be in the baby’s environment.

Other bioactive factors

Bile-salt stimulated lipase facilitates the complete digestion of fat once the milk has reached the small intestine. Fat in artificial milks is less completely digested.

Epidermal growth factor stimulates maturation of the lining of the infant’s intestine, so that it is better able to digest and absorb nutrients, and is less easily infected or sensitized to foreign proteins. It has been suggested that other growth factors present in human milk target the development and maturation of nerves and retina.

Colostrum and mature milk

Colostrum is the special milk that is secreted in the first 2–3 days after delivery. It is produced in small amounts, about 40–50 ml on the first day, but is all that an infant normally needs at this time. Colostrum is rich in white cells and antibodies, especially sIgA, and it contains a larger percentage of protein, minerals and fat-soluble vitamins (A, E and K) than later milk. Vitamin A is important for protection of the eye and for the integrity of epithelial surfaces, and often makes the colostrum yellowish in colour.


This study aimed to determine the prevalence of exclusive breastfeeding, knowledge, and attitude and associated factors affecting it. Ninety-seven percent of the mothers were practicing breastfeeding with only three percent who had not breastfed because of breast swelling, oral candidiasis, no enough breastmilk and abandonment by the mother. This study revealed that the prevalence of exclusive breastfeeding practice for infant in their first six months of life was thirty- five percent(35%), this finding is lower than the 2010 Sudan household survey which found out that forty-five percent of the babies in Southern Sudan were exclusively breastfed (12). Our finding is much higher than in Lebanon (10%), almost equal to Bangladesh (36%) and lower than the exclusive breastfeeding prevalence in Ethiopia (49%) (51,52). This decline in the trend of exclusive breastfeeding blamed is on the mothers not adhering strictly to the World Health Organization recommendation of EBF for the first six months. In addition to socio-cultural practices of early introduction of water, infant formula, soup, porridge and others before six months of age. This is confounded by misleading advertisement of formula milk in the market which might have contributed negatively to exclusive breastfeeding.

Although 67.5% of the participants had adequate knowledge on the definition of EBF, the practice was relatively lower (35.0%) compared to the WHO recommendations for exclusive breastfeeding in developing countries. The average knowledge of the respondents about exclusive breastfeeding is about seventy six (76%).

Our study participants highly valued the immune benefits of breastfeeding 97.6%. It was found out that majority of the respondents had positive attitude towards exclusive breastfeeding (85.4%) but only 33.4% of them exclusively breastfed. We found that those participants who were mixed or formula feeding were more likely to have negative attitudes towards breastfeeding (13.6%), including thinking that breastfeeding was embarrassing and difficult in public Places (39%), it may be difficult if someone else feeds/cares for the child, and physically painful and uncomfortable and were likely to be influenced by the negative attitudes of family members or friends. Other studies that have evaluated the relationship between attitudes towards breastfeeding and breastfeeding intention have found that partner or friend/family support is important as is confidence or prior experience and fear of pain in deciding not to breastfeed.

Mothers between the ages group 16-25 years showed the highest percentage (17.9%) of exclusive breastfeeding in this study which was significantly ( p<0.05) different from mothers in the age group 26-35 years ( 16.3%) and age group 35-45 ( 0.8 % ) .This finding disapproved our third research hypothesis “ elderly mothers were more likely to exclusively breastfeed compared to young mothers”. This may be attributed to higher frequency registered in this age group, in addition to good advices given by grandmothers who are perceived to be key decision makers when it comes to good parenting.

Maternal literacy (25.2%) was observed to favour exclusive breastfeeding significantly (p<0.05) was compare to illiterate mothers (9.8%). This may be due to their understanding of the health implication of exclusive breastfeeding on infant’s health. This is in the support of the finding in Jos, Plateau state Nigeria (53). Our finding is contrary to the result obtained from Ethiopian demographic health survey, which indicated a declining trend of exclusive breastfeeding with the higher maternal education status (52).

This study has indicated a significant difference among employed mothers (6.5%) with unemployed mothers (28.5%) with regard to exclusive breastfeeding. It also revealed that unemployment is a predication of exclusive breastfeeding which is consistent with the finding of the case study done in Wad Medani Sudan (54).This might be explain by the fact of less maternity leave ( two month after delivery in our context ), which makes employed mothers to have less opportunity to stay at home , compromising exclusive breastfeeding. Mothers also may have to leave their babies to search for a job. These finding calls for policy augments to initiate breastfeeding friendly work environment, as well as the extension of maternity leave to encourage mothers to exclusively breastfeed their babies to improve child health outcome.

Our study found that religion affect exclusivity of breastfeeding, with Christian women (34.1%), Muslim (0.8%), non-religious women did not exclusively breastfeed their infants (0.0%).

This current study showed that mothers who do not have chronic illness constitutes (91.9%) out of which a third (32.5%) exclusively breastfed compared to 8.1% of those mothers who had chronic illness. This could be due to the fact that these mothers might have decreased breastmilk production due to the stress of the disease causing them to opt for mixed feeding.

The current study showed that the attendance of antenatal care (ANC) clinic (88.6%) enhanced mothers‟ knowledge and appreciation of the demands and benefits of exclusive breastfeeding, and empowers them to resist external interferences and pressures. Out of the above percent about a third (31.7%) exclusively breastfed. This could be due to the health Education about exclusive breastfeeding they received on their ANC visits. Though majority of the mothers attended ANC at least eight percent of them did not had their infants immunized.

According to our finding as the age of the infant approached six months, the rate of exclusive breastfeeding decreased significantly, which is similar to others studies done in Uganda, Sudan and Ethiopia (55, 54, 52). This might be due to the fact that postpartum care is traditionally given in the first few months after birth where mothers remain at home, creating a chance to exclusively breastfeed their infants. The other possible reason is that the mother might have introduced complementary feeds for their infants due to the assumption that breastmilk alone could not satisfy their needs as the infant gets older. As the child grows the rate of exclusive breastfeeding decreases as explained by the short birth interval since some mothers had other children of less than two years at home.

There was an association between presence of other dependents (elders and toddlers) at home and exclusive breastfeeding, mothers not having others dependents (15.4%) have higher rate of exclusive breastfeeding compared to those who had other dependents (13.8%); This could be due to competition for the available resources at home, overworking of the mothers leading to reduced breastmilk production as a result complementary foods are introduced early.

Strengths and Limitations

The use of validated questionnaires, quantitative method of data collection is the strengths of this study. However, the 24-hour recall to determine exclusive breastfeeding practice means some infants who were given other liquids regularly may not have received them in the last 24 hours before the interview, which may cause overestimation of the proportion exclusively breastfed. Similarly Children who have not been receiving other fluids regularly but had been given liquid in the past 24-hour recall method can underestimate the actual EBF rate in the population studied.

Several authors have questioned the validity of the 24-hour recall method (55). The major criticism of the 24-hour recall method is that it misclassifies too many mothers as exclusively breastfeeding; a proportion of mothers may be providing substances other than breast milk on an irregular, not daily, basis. Many studies have shown that a large proportion of infants who were exclusively breastfed in the previous 24 hours were either not exclusively breastfed during the previous seven days, and/or, not exclusively breastfed since birth.(55)

Median duration can also be affected by maternal recall, which might be prone to recall and social desirability bias. Therefore, readers are recommended to take this into account during interpretation of these findings. In addition, there are also some variables that were not significantly associated (however known in several studies) with the outcome of interest which might affect the precision. This might be due to the sample size, which might not be adequate to justify the relationships between the explanatory variables and outcome of interest. Therefore, any interpretation of this finding should take into account.



Based on the findings, breastfeeding mothers are faced with multiple challenges as they struggle to practice exclusive breastfeeding. Thus, scaling up of EBF among mothers requires concerted efforts at the macro, meso and micro levels of south Sudanese society.

Exclusive breastfeeding is unlikely to be practiced if mothers continue to face problems with breastfeeding without adequate support. As a result, counselling for mothers on EBF needs to be improved and healthcare workers need to be better trained to provide counselling services.

Our findings suggest that additional support for mothers and their infants within the first six months of life is critical for better breastfeeding practices. We found that most of the predicators of exclusive breastfeeding are intertwined in the socio-cultural practices of giving water, soup, powdered milk or goat/cow milk and other food stuffs. Mothers were less likely to breastfeed exclusively if they were illiterate, elderly, and did not attend ANC during pregnancy.

It is evident from the literature and results that knowledge and attitude plays a key role in the practice of exclusive breastfeeding, as such there is dire need for interventions on exclusive breastfeeding, targeting not only mothers but also influential members of the family.


The paramount significance of exclusive breastfeeding practice is to promote the growth, survival and health of infants. The promotion and acceptance of the practice is important in South Sudan where there is high level of poverty, disease burden and low access to clean water and good sanitation.

  • The adoption and implementation of the WHO/UNICEF Global strategy for infants and young child feeding (IYCF) at all healthcare levels in the ten states of the Republic of South Sudan will have a positive impact on promotion of EBF practices.
  • More funds must be allocated to IYCF activities to reduce infants and child mortality through improved breastfeeding and appropriate complementary feeding practices. This call for commitment on the ministry of health which is crucial for the successful development and implementation of IYCF strategies and interventions.
  • We strongly recommend the adoption of the Baby Friendly Hospital Initiative (BFHI) in the Republic of South Sudan with the aim to provide mothers and their infants a supportive environment for breastfeeding and to promote appropriate breastfeeding practices, thus helping to reduce infant morbidity and mortality rates.
  • Breastfeeding education in terms of knowledge and attitude through mothers‟ support group (MSG).
  • Healthcare providers capacity building; better training is needed to equip them with the knowledge necessary to conduct outreach activities and counselling services on EBF. In addition to sending some South Sudanese for training to become lactation consultants.
  • There is great need to create awareness of optimal breastfeeding practices to women of child bearing age, behavioral change among mothers. Furthermore, interventions need to be scaled up to empower mothers with chronic diseases to practice exclusive breastfeeding and to educate family members in conjunction with mothers about the benefits of EBF and the public as well.
  • Policies aimed at improving EBF uptake should incorporate Grandmothers, mothers-in law and husbands in the process of encouraging breastfeeding mothers because of the active role they play in encouraging EBF practices.


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