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Table of Contents
ORIGINAL ARTICLES
Year : 2020  |  Volume : 25  |  Issue : 2  |  Page : 57-69

The roles of social networks and social support on breastfeeding practices in Nigeria


1 Department of Social and Behavioral Sciences, Harvard T.H. Chan School of Public Health, Boston, USA
2 Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, USA

Date of Submission30-Dec-2019
Date of Decision02-Mar-2020
Date of Acceptance23-Mar-2020
Date of Web Publication29-Jul-2020

Correspondence Address:
Emeka P Agudile
Department of Social and Behavioral Sciences, Harvard T.H. Chan School of Public Health, 677 Huntington Ave, Boston, MA 02115,
USA
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijmh.IJMH_44_19

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  Abstract 

Background: The global prevalence of early breastfeeding initiation, exclusive breastfeeding, and avoidance of prelacteal feeding has remained below the recommendations by the World Health Organization. Nigeria has the lowest rates of exclusive breastfeeding and the highest rates of prelacteal feeding in sub-Saharan Africa. It has been shown that social support is positively associated with healthy breastfeeding practices. Materials and Methods: This study used data from the household interviews of the Pilot Study on the Quality of Care in Antenatal Care and Patterns of Maternal Health Behavior in Nigeria, a cross-sectional survey of women (n = 455) in Nigeria to investigate the association between social support and breastfeeding practices among women. We conducted multivariable logistic regression analyses to explore the association between sources and types of social supports and breastfeeding in Nigeria. Results: We found that supports from mothers and fathers were associated with a higher prevalence of early breastfeeding initiation (odds ratio [OR] = 1.91; 95% confidence interval [CI] = 1.03–3.53; P = 0.039) and avoidance of prelacteal feeding (OR = 2.20; 95% CI = 1.08–4.49; P = 0.030), respectively. On the other hand, supports from neighbors (OR = 0.40; 95% CI = 0.24–0.64; P < 0.001) and mothers-in-law (OR = 0.46; 95% CI = 0.22–0.96; P = 0.039) were negatively associated with early breastfeeding initiation. Other sources of support were not significantly associated with either breastfeeding initiation or prelacteal feeding. Also, high levels of physical support from all network members were associated with a higher likelihood of avoiding prelacteal feeding (OR = 2.94; 95% = CI 1.65–5.22; P < 0.001). In contrast, high levels of emotional support from all network members were associated with a higher risk of prelacteal feeding (OR = 0.61; 95% CI = 0.37–0.98; P = 0.045). Conclusion: Our findings suggest that there are significant dual roles of social support from older generations on breastfeeding. Physical support during the postpartum periods may discourage prelacteal feeding in Nigeria.

Keywords: Breastfeeding initiation, exclusive breastfeeding, maternal, Nigeria, prelacteal feeding, social networks, social support, sub-Saharan Africa


How to cite this article:
Agudile EP, Okechukwu CA, Subramanian SV, Geller AC, Langer A. The roles of social networks and social support on breastfeeding practices in Nigeria. Int J Med Health Dev 2020;25:57-69

How to cite this URL:
Agudile EP, Okechukwu CA, Subramanian SV, Geller AC, Langer A. The roles of social networks and social support on breastfeeding practices in Nigeria. Int J Med Health Dev [serial online] 2020 [cited 2020 Aug 14];25:57-69. Available from: http://www.ijmhdev.com/text.asp?2020/25/2/57/291064




  Introduction Top


Breastfeeding confers numerous short- and long-term physical and mental health benefits for infants and mothers, and economic benefits for society.[1] A strong body of research demonstrates that breastfeeding is associated with lower risks of infant and child mortality due to infectious diseases, and also reduced risks of breast and ovarian cancer for mothers.[2] Consequently, the World Health Organization (WHO) has the following recommendations regarding breastfeeding: (1) timely initiation of breastfeeding within 1h after delivery, (2) avoidance of feeding the newborn with any food or drink during the first few days of birth (i.e., prelacteal feeding), (3) exclusive breastfeeding (EBF) for all infants for the first 6 months of life, and (4) after the first 6 months, infants should be given complementary foods with optimal continuation of breastfeeding for 2 or more years.[2],[3]

Despite the documented evidence of the health and emotional benefits of breastfeeding, early establishment and EBF remain low in most countries.[4] About 38% of women in Nigeria initiate breastfeeding within 1h of birth,[5] 59% of them practice prelacteal feeding,[6] and only 17% breastfeed exclusively for 6 months.[7] In fact, Nigeria has the highest prevalence of prelacteal feeding and lowest rates of EBF in sub-Saharan Africa.[6] It has been shown that prelacteal feeds interfere with early initiation of breastfeeding, disrupt EBF, and increase the risk of neonatal infection and mortality.[6],[8]

Evidence from different countries has underscored the importance of social support and social network on a mother’s breastfeeding behaviors.[1],[9] There is a wealth of literature on studies that have evaluated the impact of social support from both formal/professional social networks (healthcare workers, doulas, and breastfeeding consultants) and informal social networks (family, friends, and peers) on breastfeeding practices. Some systematic reviews and an intervention study note positive associations between social support and healthy breastfeeding practices,[4],[10] but other reviews note mixed results.[11],[12] Research shows that non-tangible support and tangible support influence breastfeeding behavior through different pathways. While non-tangible support is mainly concerned with the maintenance and transfer of healthy breastfeeding attitudes, tangible support targets the costs and benefits surrounding breastfeeding.[13] It has also been shown that women are more likely to seek emotional social support from their significant others compared to men.[14]

Social support refers to the psychological and material resources provided by a network of family, friends, neighbors, and community members in times of need. It falls into four distinct domains: emotional support (provision of empathy, love, trust, and caring), instrumental support (provision of tangible aid, and services, e.g., financial aid), informational support (provision of advice, directives, and suggestions), and appraisal support (provision of affirmation, constructive criticism, and feedback).[15] There are several hypothesized ways through which social support impacts people’s health, although there is very little accepted theory about how social support or its components exerts its beneficial effect.[16],[17] Social support may (1) exert direct beneficial impact on health through the provision of basic human needs for intimacy, companionship, reassurance, and a sense of belonging;[17],[18] (2) buffer the adverse effect of stressors by enhancing individual coping resources and community resources, and also influence the frequency and duration of exposure to stressors;[16],[17],[18] (3) exert potential effect on health behavior and alter patterns of health-related behaviors through the interpersonal exchanges within a social network where individuals are supported and influenced in such health behaviors.[19]

Many studies across Nigeria have shown that social support and social networks may have a positive impact on mental health outcomes,[20] postnatal depression,[21] compliance to hypertension treatment,[19] utilization on mental health services,[22] and coping with stroke.[23] Few studies, however, have explored the relationships between formal or informal social support and breastfeeding practices in Nigeria.[24],[25],[26],[27]

There are still significant knowledge gaps in the association between social support and breastfeeding practices, especially in Nigeria. No studies, to the best our knowledge, have explored the differential effect of all the possible different sources (i.e., spouse, mothers, fathers, siblings, friends, neighbors, mothers-in-law, co-wives) or different types (i.e., emotional, e.g., love; informational, e.g., advice; physical, e.g., household chores; and financial, e.g., monetary gifts or loans) of social support[28] on breastfeeding initiation and prelacteal feeding.

To address some of these gaps, we conducted a cross-sectional study of more than 400 women in Keffi, north-central Nigeria, to investigate the associations between social support and breastfeeding practices among Nigerian women. We investigated the following: (1) whether the different sources of social support have a differential impact on women’s breastfeeding practices (i.e., breastfeeding initiation and prelacteal feeding) and (2) whether specific types of social support are associated with early initiation of breastfeeding and avoidance of prelacteal feeding.

Different people have different preferences for the various types of social support and from whom they seek assistance. Previous studies show that kin and nonkin social supports are associated with separate and distinctive outcomes in the perceptions and reliability of support and psychosocial well-being.[29] Some researchers found that kin support may have stronger associations with psychological health outcomes compared to nonkin support.[30] We hypothesized that there would be a higher prevalence of healthy breastfeeding practices (early initiation and avoidance of prelacteal feeding) among women who received social support from their network members compared to those who did not receive support from their network members. At the same time, we hypothesized healthier breastfeeding behaviors among women who received social support from their family members (e.g., spouses, parents, or siblings) compared to those who received support from nonfamily members (e.g., friends or neighbors).

We also hypothesized that non-tangible support (e.g., emotional and informational supports) would be more predictive of early initiation of breastfeeding and avoidance of prelacteal feeding compared to tangible support (e.g., financial and physical supports).


  Materials and Methods Top


Ethical clearance

The Nasarawa State Ministry of Health Ethical Committee and the Harvard T.H. Chan School of Public Health Institutional Review Board Committee reviewed and approved the ethical clearance for our research. Informed consent was obtained from all participants who consented to be part of this study.

Study population

This study used data from the household interviews of the Pilot Study on the Quality of Care in Antenatal Care (ANC) and Patterns of Maternal Health Behavior in Nigeria. The pilot study conducted cross-sectional surveys of approximately 1500 adult men and women living in Nasarawa State, north-central Nigeria, between October 2013 and July 2014. The pilot study had two components: facility-based components and population-based components. The population-based parts involve conducting both household interviews and community leader interviews. The data used in this study were derived from the household interviews of the population-based component of the pilot study. The household interviews included a segment that assessed the respondents’ social networks and social support.

Sampling technique

A multistage random sampling technique was utilized to select participants for the study. The first stage involved randomly selecting 40 communities, representing urban and rural settings, of the 72 communities in Keffi Local Government Area of Nasarawa State for the household interviews. In the second stage, 13 households were then randomly selected from each community (40 × 13 = 520 households). The selection of the households was carried out by starting with a random number drawn from a list of numbers with starting point one and endpoint the total count of the households in each community and then selecting each nth household (where n = total number of households/13). In the third stage, three adults (both men and women) were selected randomly within each household to yield a target sample size of about 1500 for the household interview (520 × 3 = 1560).

Both components of the pilot study were powered to detect a 10% point difference from a postulated proportion of 50% (which is conservative compared to other proportions and an estimate commonly found in empirical investigations of the correct performance of ANC procedures in East Africa)[31],[32] at 5% significance level and with 90% statistical power. While accounting for the design effect due to the multistage cluster survey design, assuming an intra-class correlation of 0.1 and 13 randomly selected primary sampling units, the required sample size is 450 for the secondary sampling units (i.e., community members). To ensure precise measurement when individuals do not fully participate in the planned survey interviews, we added a 20% safety margin to this sample size, leading to a sample size of 540 for the secondary sampling units for the population-based household interviews.

Sample size

All the 647 (43%) male respondents that completed the survey were dropped from our analytic sample. About 853 (57%) women completed the study, but about 380 of them have never breastfed a child and hence were not included in our analytic sample. Also, 18 women who were aged more than 40 years were dropped from our sample to minimize recall bias. We assumed that these women were either perimenopausal or postmenopausal at the time of the interview because it had demonstrated that the mean and median ages of menopause in Nigeria were 48.4 and 48.0 years, respectively.[33] The most recent births for these peri- and postmenopausal women may have been many years ago, and as social support is a dynamic, interactive process, we assumed that their social support networks might have evolved over these years. The eligible analytic sample for the current analysis included 455 (30%) women who had breastfed at least one child and were 40 years old or less at the time of the interview.

Data collection

The study questionnaire assessed general perceptions of the quality of ANC, as well as beliefs about ANC effectiveness and usefulness, and respondents’ social networks and social support, and on pregnancy-related experiences, including breastfeeding practices. Data for this study were collected through semi-structured face-to-face interviews of eligible respondents. Bilingual (English and Hausa) research assistants that had been trained in a semi-structured interviewing technique administered the interviews using our household survey questionnaire. The research assistants filled out the questionnaire with answers from the respondents during the interview process.

Dependent variables

The outcome variables of interest are mothers’ self-reported breastfeeding practices during the first 3 days following their last delivery. The respondents were asked if they breastfed their last child. Those who responded “yes” to this question were asked follow-up questions, including (1) “How long after birth did you first put the newborn to the breast?” (we dichotomized their answers into “early breastfeeding initiation” if the newborn was put to the breast within an hour after birth and “late breastfeeding initiation” if the newborn was put to the breast more than an hour after birth) and (2) “In the first three days after delivery, was the newborn given anything to drink or eat before breastfeeding?” Each respondent’s answer to this question on prelacteal feeding was coded as “1” if he/she answered “no” and “0” if he/she answered “yes.”

Independent variables

Instrument

Social networks and social support were measured using the Close Persons Questionnaire (CPQ), which measures multiple dimensions of social support.[34] The CPQ assesses both the structural and functional aspects of social support by including questions on both social networks (sources of social support) to represent the structural aspects of social support, and quality of social support (different types of social support) to represent the functional aspects of social support.[34] Questions from Berkman and Syme[35] assessed sources of support, including frequency of contact with relatives, friends, neighbors, and so on. Questions on the different types of social support explored four different functional aspects of social support: emotional (e.g., empathy, love, trust, and caring), instrumental (e.g., tangible aid, money, gifts, and services), informational (e.g., advice, suggestions, and health information), and appraisal support (e.g., constructive feedback and affirmation). The format of the questions was derived from Schaefer et al.[36] and Power et al.[37]

Sources of social support

To delineate egocentric social networks (sources of social support), the respondents (egos) were invited to generate names of up to six close adults (alters) whom they were in communication with and who provided any form of support to them in the past 6 months. Follow-up questions asked each respondent to identify their relationships with each of the six adults named earlier (e.g., spouse, mother, father, siblings, co-wife, friend, neighbor, or mother-in-law) as well as their frequency of contact/interaction.[38],[39] Further details on the sex, age, and educational attainment of each of the members of their social networks were collected from the respondent. We generated new variables named “spouse,” “mother,” “father,” “sibling,” “co-wife,” “friend,” “neighbor,” and “mother-in-law” across all the named alters to represent the sources of social support. Each of the sources of social support (e.g., spouse) was treated as a binary variable and coded as “1” for respondents that got support from their spouses (yes) and “0” for respondents that did not get support from their spouses (no).

Types of social support

Each respondent was asked how frequently they received each kind of social support (emotional, informational, physical, and financial/instrumental support) from the six alters they had identified earlier using a grid method. The aim was to assess the level of functional social support from these six sources of support. Descriptions of each type of social support, adopted from Wills and Shinar’s definitions, were provided and explained to the respondents.[40] The frequency of receipt of each of the types of support was measured on a 7-point scale: “1” if they received support every day, “2” if they received support a few times per week, “3” if they received support once per week, “4” if they received support a few times per month, “5” if they received support once per month, “6” if they received support a few times per year, and “7” if they received support once per year or less.[39],[40] We calculated the total score of each respondent’s frequency of receipt of each type of support across all the named alters (i.e., a minimum of 6 and a maximum of 42).[41] As the total scores of the different types of support were normally distributed among our study participants, we adopted the 50th percentile (median) for each kind of support as the cutoff between high and low frequency of support. Also, we chose the concept of high and low levels of social support to align with similar strategies adopted by previous researchers in the field.[39] The frequency of receipt of each type of support was treated as a binary variable (high vs. low).

Confounders

The sociodemographic variables included in our analyses are age (continuous), number of life births (continuous), education (high school or more/less than high school), employment (employed/unemployed), marital status (married/unmarried), and ever lost a child (yes/no). Age and number of live births were stratified into three categories each (18–30 years, 31–40 years, and more than 40 years, and 1–2 live births, 3–4 live births, and more than four live births, respectively) for descriptive purposes and employed as continuous variables in all analyses.

Statistical analysis

All analyses were conducted using STATA, version 12.0 SE (StataCorp, College Station, TX).[42] Descriptive statistics were used to examine the characteristics of the study sample. We then estimated the bivariate relationship between the sociodemographic variables and breastfeeding practices using a chi-square test. The distributions of the different sources and types of social support were shown in [Table 1].
Table 1: Distribution of sources, types/frequency of social support reported by the women N = 455

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Finally, multivariable logistic regression analyses were conducted to examine the association between each of the different sources and types of social supports and each of the breastfeeding practices (breastfeeding initiation and prelacteal feeding) using the logit link function in STATA. Each of the sources (e.g., spouse) and types (e.g., emotional) of social support was treated as a binary variable and modeled as an independent variable in the multivariable logistic regression models. The odds ratio (OR) and the 95% confidence intervals (CIs) were derived in each case.

We conducted four multivariable regression models to estimate the unadjusted, partially adjusted, and fully adjusted associations of each source and type of social supports and breastfeeding initiation. In model 1, we assessed the crude associations of sources of social support and breastfeeding initiation. In model 2, we estimated the crude associations of types of social support and breastfeeding initiation. In model 3, we partially adjusted for both the sources and types of social support. In model 4, we fully adjusted for both sources and types of social support and sociodemographic variables. We also conducted four multivariable regression models to estimate the unadjusted, partially adjusted, and fully adjusted associations of each source and type of social supports and prelacteal feeding.


  Results Top


Sociodemographic characteristics according to breastfeeding practices

[Table 2] presents the sociodemographic characteristics of the women stratified according to breastfeeding initiation and prelacteal feeding. The mean age of the participants was 29.0 (standard deviation [SD] = 5.6). The average number of live births by the women was 4.3 (SD = 2.7). More than half of the women (53%) had attained an elementary educational level or less. About 75% of the women were unemployed, more than 94% was married, and only 28% had ever lost a child.
Table 2: Socio-demographic characteristics of the women stratified according to breastfeeding practices N = 455

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[Table 2] also shows that about 68% of women initiated breastfeeding within 1h of delivery, while about 65% avoided prelacteal feeding of their newborn during their last childbirth. Overall, about 45% of the women initiated breastfeeding early and avoided prelacteal feeding, 22% initiated early but practiced prelacteal feeding, 20% initiated late but avoided prelacteal feeding, and only 12% initiated late and practiced prelacteal feeding (data not shown on the table).

In general, there are no statistically significant differences in the proportions of participants that reported early initiation or avoidance of prelacteal feeding according to the different categories of sociodemographic characteristics. However, more educated women were more likely to avoid prelacteal feeding compared to the less educated ones (73% vs. 59%, P = 0.002). Also, participants that had ever lost a child were more likely to initiate breastfeeding early compared to those that had never lost a child (75% vs. 65%, P = 0.035).

Distribution of sources and types/frequency of social support among the women

[Table 1] presents the distributions of the different sources and types/frequencies of social support reported by the women. About 48% of the women reported receiving social support from their spouses. More than 23% received support from their mothers, whereas only 15% received support from their fathers. More than 67% of them reported receiving support from their siblings, about 72% of them received support from their friends, and 54% received support from their neighbors.

In comparison, only 18% and 11% of them received support from their co-wives and mothers-in-law, respectively. The distributions of the frequencies of receipt of the different types of social support indicate that about 57% and 52% of the participants reported receipt of high levels of emotional and financial support, respectively. On the other hand, only 48% and 43% of the participants reported receipt of high levels of informational and physical support, respectively.

Multivariable logistic regression of the association between the sources and types of social support and breastfeeding initiation

[Table 3] displays the results of multivariable models estimating associations between the sources and types of social support and breastfeeding initiation adjusted for sociodemographic variables. Women who received social support from their mothers have statistically significant higher odds of initiating breastfeeding early compared to women who did not receive any support from their mothers (OR = 1.91, 95% CI: 1.03–3.53; P = 0.039). On the other hand, women who received support from their neighbors and their mothers-in-law were less likely to initiate breastfeeding early compared to those that did not receive support from their neighbors and their mothers-in-law (OR = 0.40, 95% CI: 0.24–0.64, P < 0.001 and OR = 0.46, 95% CI: 0.22–0.96, P = 0.039, respectively). There are no statistically significant relationships between the other sources of social support and breastfeeding initiation. Also, there are no significant associations between any particular types of social support and breastfeeding initiation.
Table 3: Multivariable logistic regression of the association between the sources and types of social support, and breastfeeding initiation

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Multivariable logistic regression of the association between sources and types of social support and prelacteal feeding

[Table 4] shows the results of multivariable models estimating associations between sources and types of social support and prelacteal feeding adjusted for sociodemographic variables. Women who received high levels of physical social support from their network members have statistically significant higher odds of avoidance of prelacteal feeding of their newborns compared to women who received low levels of physical social support (OR = 2.94, 95% CI: 1.65–5.22; P < 0.001). On the other hand, women who received high levels of emotional support have a statistically significant lower likelihood of avoidance of prelacteal feeding compared to women who received low levels of emotional social support (OR = 0.61, 95% CI: 0.37–0.98; P = 0.045). Finally, women that received social support from their fathers have a statistically significant higher likelihood of avoidance of prelacteal feeding compared to those that did not receive any support from their fathers (OR = 2.20, 95% CI: 1.08–4.49; P = 0.030). The other sources and types of social support did not have any significant statistical associations with prelacteal feeding.
Table 4: Multivariable logistic regression of the association between the sources and types of social support, and pre-lacteal feeding

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Also, multivariable logistic regression of the association between sources and types of social support, and a combined outcome of both breastfeeding initiation and prelacteal feeding, showed nonsignificant associations with any of the predictor variables (data not shown).


  Discussion Top


We investigated the cross-sectional association between different sources and types of social support and breastfeeding practices (breastfeeding initiation and prelacteal feeding) among women in Nigeria. This study revealed four salient findings: (1) women who received social support from their mothers were more likely to initiate breastfeeding early compared to women who did not receive maternal social support. Also, women who received social support from their fathers were more likely to avoid prelacteal feeding compared to those who did not receive paternal social support. (2) Receipt of social support from neighbors and mothers-in-law was negatively associated with early breastfeeding initiation. (3) Women who received high frequency of physical social support from their network members were more likely to avoid prelacteal feeding of their newborn compared to women who received low levels of physical support. Finally, (4) receipt of high levels of emotional social support compared to low levels of emotional support is associated with a higher risk of prelacteal feeding among our study participants.

Our findings of a positive association between parental support and healthy breastfeeding practices are consistent with results from other studies. These studies conclude that older generations (especially grandmothers) exert a significant positive impact on breastfeeding practices, especially when these older female generations have favorable attitudes to breastfeeding.[7],[43] Studies have shown that in Nigeria, as well as in other developing countries, the older generation especially the infant’s grandmothers (i.e., mother’s mother), mothers-in-law (i.e., father’s mother), and other older relatives play very significant roles as caregivers on issues regarding reproductive and child health, and child-rearing in the family.[7],[43] Decisions on various aspects of pregnancy, childbirth, and breastfeeding practices are influenced by the older generation either directly or indirectly. Given these culturally prescribed roles and values, cultural expectations, and limited parental knowledge on, and attitudes to, breastfeeding are, therefore, essential determinants of breastfeeding practices by Nigerian women. Therefore, parents with a positive disposition to exclusive and early breastfeeding initiation are more likely to support and encourage their daughters or daughters-in-law to initiate breastfeeding early, avoid prelacteal feeding, and breastfeed exclusively.[44] Supportive resources and guidance provided by parents during the immediate postpartum period could work to mitigate psychosocial and physical stressors associated with childbirth.

This study also reveals that social support from mothers-in-law (i.e., paternal grandmother) have statistically significant negative associations with early breastfeeding initiation. Some previous studies found that grandmothers may have a positive impact on breastfeeding,[7],[43] whereas others found a negative influence on breastfeeding by grandmothers.[27] These studies, however, did not distinguish between maternal and paternal grandmothers (i.e., mothers-in-law) as our study did. In Nigeria and elsewhere, stereotypes stemming many years back portray the mother-in-law as the most problematic family tie.[45],[46] In Nigeria, especially, cultural stereotypes portray mothers-in-law in a predominantly pejorative and negative image, to the extent that most prospective daughters-in-law develop a phobia for their future mothers-in-law even before marriage.[46] Despite this widely held stereotype and consequent pervasiveness of unhealthy mother-in-law/daughter-in-law relationships in Nigeria, few studies have been undertaken to unravel the true nature of this relationship and its impact on family life. One study, however, affirms that the majority of the mother-in-law/daughter-in-law relationships in Nigeria are frosty, unhealthy, and conflict-ridden.[46] It has been shown that cultural stereotypes and strained relationships can be internalized and unconsciously shape behaviors.[45] If daughters-in-law embrace negative expectations of their mothers-in-law or assume that their mothers-in-law are undermining them, they may engage in unhealthy breastfeeding practices, despite receiving social support from their mothers-in-law. They might be doing this as a way to either register their displeasure or assert their autonomy.

Few studies have explored the influence of neighbors on breastfeeding practices. One study noted that some women preferred to seek advice from their neighbors with previous breastfeeding experience, because they believed that others’ experiences were significant to them during lactation.[47] On the other hand, another study noted that women who listened to their neighbors’ advice were less likely to practice EBF.[48] More often than not, the advice and recommendations from neighbors are not based on sound medical expertise and hence more likely to be unreliable or incorrect, and may lead to unhealthy breastfeeding practices. At the same time, these sources of advice may reinforce myths, cultural beliefs, and misinformation related to breastfeeding.

Our study found no significant associations between other sources of support (spouse, sibling, friend, co-wife) with either breastfeeding initiation or prelacteal feeding. These observations are perplexing to discern, particularly the null associations between spousal social support and breastfeeding practices. The finding of no statistically significant association between spousal support and breastfeeding behaviors aligns neither with our hypothesis of a positive association nor with results of dual roles of significant others from previous studies. Some past studies revealed that supportive spousal actions might lead to improved breastfeeding behaviors.[49] In contrast, others found that the partner’s negative attitudes (e.g., belief that breastfeeding makes the breast flabby), conflicting positions, and nonacceptance of breastfeeding might constitute significant constraints.[7],[50],[51]

The absence of any significant associations between spousal support and breastfeeding practices in this study could be related to the cultural perceptions of the father’s primary role as the breadwinner and the head in a typical African family. These cultural perceptions of masculinity emphasize the provision of material and financial support for the family as the primary roles of the father. At the same time, issues related to child-rearing and nutrition, such as breastfeeding practices, were considered as exclusive female responsibilities.[50],[51] The perceptions of fathers as passive or neutral observers on the breastfeeding process may have conditioned breastfeeding mothers to underestimate, discount, or dismiss the importance of spousal support during breastfeeding. Also, the exclusion or sidelining of fathers from the breastfeeding relationships may have led to their limited understanding of challenges associated with breastfeeding, and to a mismatch in couples’ perceptions of what constituted social support for breastfeeding.

Our findings also indicate that women who received high levels of physical social support from their network members were more likely to avoid prelacteal feeding of their newborns compared to those who received low levels of physical support. Some of the predictors of prelacteal feeding include young age, low socioeconomic status, home delivery, cultural belief systems, and postpartum stressors (e.g., cesarean sections, episiotomies, instrumental deliveries, and breastfeeding difficulties).[6],[8] Most importantly, previous research notes that high rates of operative and instrumental deliveries in developing countries contribute to high rates of prelacteal feeding because the pain and discomfort associated with these procedures interfere with prompt and proper breastfeeding.[8] Evidence from Nigeria shows a very high prevalence of episiotomy that ranges from 34.4% to 65.6% compared to the 10% recommended by the WHO.[52],[53] So, assisting the Nigerian parturient with physical support such as provisions of food or food preparations, childcare, purchasing hospital consumables, paying bills, and other domestic errands/housework would free up enough time for her to rest and recover from the discomfort and pain associated with the childbirth. This high level of physical support could translate into more time spent on feeding the newborn with human breast milk instead of breast milk substitutes. Moreover, experienced network members could serve as informal lactation consultants and counselors through guidance and demonstrations on proper breastfeeding techniques (e.g., positioning and latching the newborn at the breast) and procedures for breast milk extraction. This type of physical support has also been shown to be highly effective in overcoming pain and difficulties associated with breastfeeding due to blockage and cracked nipples, especially in areas where professional support is not widely available such as Nigeria.[54],[55]

Finally, our analysis shows that women who reported receipt of high levels of emotional support from their network members were more likely to practice prelacteal feeding compared to those who received low levels of emotional support. Breastfeeding is associated with a complex array of positive and negative psychosocial and emotional experiences that may be somewhat contradictory.[56] More often than not, the mainstream cultural and biomedical narratives expect new mothers to present an easy and positive attitude and relationship with breastfeeding, but this may not always reflect the true situation of some mothers. Apart from the positive experiences such as joy for a successful childbirth and the intimate and harmonious relationship with the newborn, some women may also experience some negative emotions such as shame and social embarrassment of breastfeeding in front of family or public, stigmatization for their breastfeeding choices or style, feeling of guilt and inadequacy, and loss of autonomy and control over their bodies/selves.[57] Also, some women might experience mental/psychological health problems such as postpartum depression, anxiety, or stress. The association between high levels of emotional support and high risk of prelacteal feeding observed in our study could be due to confounding by the psychological and mental health state of our participants. We could not control for this variable in our analyses because we did not collect the data. It has been shown that women who experience emotional distress, postpartum anxiety, or depression in the immediate postpartum periods are less likely to initiate breastfeeding early, more likely to practice prelacteal feeding or formula supplementation, and also at increased risk of reduced breastfeeding duration.[58],[59] Also, because of their negative emotional and psychosocial symptomatology, these women are also more likely to attract high levels of emotional/affective support such as empathy, encouragement, and caring from their network members. Another possible explanation for this paradoxical association between emotional support and prelacteal feeding could be reverse causation. Research has shown that women who practice prelacteal feeding or formula supplementation are more likely to report subjective experiences of guilt, inadequacy, and isolation.[60] Behavioral manifestations of these feelings by these women could attract high emotional support from their network members. It is, therefore, difficult to explain the nature or direction of the association between emotional support and prelacteal feeding from our data. Longitudinal or randomized controlled studies that would collect data on the psychosocial/mental health status among other covariates are, therefore, needed to tease out this paradoxical relationship.


  Strengths and Weaknesses Top


This study’s exploration of the differential impact of the different sources (e.g., spouses, mothers, fathers, siblings, mothers-in-law, etc.) and type of social support (emotional, financial, etc.) on breastfeeding practices adds to the existing body of knowledge in this field. Its ability to disentangle, specifically, the separate and distinctive influences of maternal versus paternal grandmothers among our study population is an interesting finding that fills a significant knowledge gap. The use of the CPQ, a validated instrument that measures multiple dimensions of social support, and the sampling design that ensured that our study sample is representative of the population add to the strength of the study.

Some of the potential limitations of this study also deserve consideration. Conclusions about causality cannot be drawn from this study, given its cross-sectional design. Furthermore, social desirability or recall bias is potentially a problem because mothers self-reported their breastfeeding practices during the first 3 days following their last delivery. Participants were informed that the information they provided was confidential to minimize bias. We believe that the impact of these biases on our results would be insignificant, given that there is little or no reason to think that our study participants differentially recalled information based on their exposure and outcome status. It is also known that women can recall their breastfeeding practices accurately after 15–20 years postpartum.[61],[62] The study was conducted in north-central Nigeria. A multisite study that includes different locations in Nigeria would have produced more generalizable data given that Nigeria is a multicultural and multiethnic country, and it is known that the impact of social support on breastfeeding practices varies according to culture and ethnicity.[63]


  Conclusion Top


Despite the limitations, our research findings highlight the significant dual roles (positive and negative) that social support from the older generations plays in the early initiation of breastfeeding by women in Nigeria. These findings underscore the need to develop evidence-based, family-centered social support interventions targeted, especially, at the infant’s grandmothers and mothers-in-laws. Such intervention must incorporate strategies to create awareness, change attitudes, and eradicate deeply rooted negative cultural beliefs and norms on breastfeeding through mass media campaigns, community advocacy, and training.

At the same time, efforts should be made to ensure that health facilities in Nigeria adopt policies and provide a supportive environment and physical comfort to new mothers to guarantee early initiation of breastfeeding and avoidance of prelacteal feeding. Relatives and hospital staff should be encouraged to assist new mothers with physical support, especially in the immediate postpartum period, to allow the mothers enough time to rest and breastfeed.

Financial support and sponsorship

This study was funded by the Maternal Health Task Force at the Women and Health Initiative in the Department of Global Health and Population at the Harvard T.H. Chan School of Public Health, Boston, through grant no. OPP1125608 from the Bill & Melinda Gates Foundation. The Bill & Melinda Gates Foundation did not play any role in neither the design of the study nor the collection, analysis, and interpretation of data, and nor in writing the manuscript.

Conflicts of interest

There are no conflicts of interest.



 
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  [Table 1], [Table 2], [Table 3], [Table 4]



 

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