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The impact of urbanization and socioeconomic status on infant feeding practices in Lagos, Nigeria

Rosemary C. Anyanwu and Cyril O. Enwonwu
National Institute for Medical Research, Yaba, Nigeria

INTRODUCTION

Breast-feeding is currently a subject of immense health and nutritional interest all over the world. As recently as 1983, the World Health Organization called attention to what it described as an impressionistic view of world-wide decline in the prevalence and duration of breast-feeding, and underscored the urgent need for more definitive data on present-day infant-feeding practices and trends, as well as information on the key factors influencing women's decisions on how to feed their babies (1). Breast-feeding for up to one year or more has been the traditional infant-feeding practice in the developing world, but recent extensive reports strongly suggest that this is rapidly giving way to the "bottle culture," especially among societies in transition mainly in pert-urban areas and in the poverty pockets of urbanized population groups (2, 3). The dimensions of this rapid, pervasive socio-cultural transformation, often erroneously regarded as a symbol of modernity, as well as the forces underlying the disturbing negative change, are not yet clearly defined.

This report covers the first phase of an on-going national study designed to evaluate current maternal perceptions of infant-feeding among different ethnic, religious, cultural, and socio-economic groups in Nigeria, with the primary objective of assessing the extent of decline in breast-feeding as well as the major factors responsible for the negative change, and how best to institute corrective educational measures. For this particular study, Surulere, a suburb of metropolitan Lagos that is heterogeneous in its ethnic and socio-economic composition, was selected as a pretest area for the widely assumed negative effects of urbanization and modernization on infant-feeding practices and the traditional African image of mothering.

MATERIALS AND METHODS

The study sample comprised 558 randomly selected Nigerian women resident in Surulere. An interview was conducted at the Gbaja and Randle Health Centres located in the area, using a standard questionnaire to obtain information on the following:

- ethnic origin of mother,
- level of education,
- mother's occupation and age,
- total income of the family,
- number of children born alive to mother,
- type of infant feeding preferred by mother and factors influencing the decision,
- age at which breast-feeding was supplemented with other foods,
- specific types of supplementary foods preferred by the mothers,
- duration of breast-feeding,
- influence of hospitals/clinics and advertisers of baby foods on choice of infant-feeding practice.

Yorubas, members of the predominant tribal group in Lagos State, constituted 55 per cent of the sample, followed by Ibos from the eastern states of the country (25 per cent). Women from the non-lbo-speaking minority groups of Bendel State constituted 10 per cent of the sample, while the remaining mothers were mainly Efiks and Ibibios from Cross River State.

Most of the women interviewed (71 per cent) were 21-30 years old, while those 16-20 years and 31-35 years accounted for 11 and 12 per cent respectively of the sample. Four mothers were under 16 years, and the rest were over 36 years of age. Twenty-four per cent of the women interviewed described themselves as full-time housewives with no readily visible occupation outside their homes, while 48 per cent were traders The rest were teachers, civil servants, nurses, seamstresses, hairdressers, and full-time students.

The women's educational qualifications were assessed by grouping them into the following major categories: no formal schooling of any type, completion of primary school education lasting about six years, completion of secondary school or its equivalent, including modern school, and graduates of university or post-secondary professional programmes. Only 12 per cent of the women belonged to the last group, while 15 per cent had had no formal schooling. The highest proportion of the sample (44 per cent) had completed primary school.

TABLE 1. Family Income Status of Study Sample

*Combined monthly income of father and mother.

TABLE 2. Number of Children Born Alive to Mother

TABLE 3. Mother's Expressed Opinion on Ideal Duration of Breast-feeding

TABLE 4. Actual Duration of Breast-feeding Practised by the Mothers

*Women who were still breast-feeding at the time of the interview.

RESULTS

Table 1 summarizes the income levels of the families studied. The estimated total monthly income per family was less than N 400 (1 naira = US$1.30) for about 56 per cent of the study sample. No fewer than 29 per cent of the families had monthly incomes below N 200, well below the subsistence level in a city rated among the most expensive in the world in terms of housing and general cost of living.

The number of children born alive to most of the women (74 per cent) varied from one to three, while 16 per cent of the women had five or more children born alive (table 2).

In the opinion of most of the mothers, breast-feeding should be practiced for as long as 7 to 12 months, while a relatively small number (less than 12 per cent) believed that breast-feeding should be restricted to only the first six months of life (table 3). Contrary to the belief of the mothers (38 per cent) that breast-feeding should continue for up to one year of life, only about 24.6 per cent of the mothers practiced breast-feeding for that long (table 4). While none of the 558 mothers interviewed was of the opinion that breast-feeding should stop before the first month, three mothers actually breast-fed their infants for less than this. As many as 64 women interviewed (about 11 per cent) admitted that they did not know how long breast-feeding should last, while a comparatively similar number (about 17 per cent) were still breast-feeding their babies at the time of the study.

Table 5 summarizes the opinions of the women regarding the appropriate age for introduction of supplementary foods. Only 4 per cent of the mothers believed that breast feeding should be supplemented for infants under one month of age. Forty-four per cent of the women suggested one to three months as the best age for introducing supplementary feeding, while about 28 per cent believed that breast-feeding should remain unsupplemented for as long as six to nine months. In marked contrast to their expressed beliefs, 43 per cent of these mothers actually introduced supplementary feeding to their infants before one month, and as many as 81 per cent used supplementary foods for infants from birth to three months (table 6). Only about 2 per cent of the women waited until their infants were six months and older before initiating supplementary feeding, an observation markedly different from their expressed opinions. In effect, these mothers did not practice their beliefs about infant feeding. The commonest reasons advanced by the women for early introduction of supplementary feeding included the following:

- the nature of work outside the home militates against prolonged breast-feeding;
- insufficient breast milk;
- supplementary feeding promotes faster growth of the baby;
- others do so.

The preferred supplementary foods used by the mothers studied included imported powdered milk or milk-based products, various locally available as well as imported canned cereals, animal proteins, and mashed beans and yams (table 7).

TABLE 5. Mothers' Opinion as to Age at Which Supplementary Feeding Should Be Introduced

TABLE 6. Youngest Age at which Supplementary Feeding Was Actually Introduced

TABLE 7. Supplementary Foods Commonly Used by Study Sample

TABLE 8. Mothers' Opinion Regarding Best Type of Feeding for Infant Aged 3-6 Months

The wide gap between the women's expressed opinions about infant feeding and what they actually practiced is further underscored by the data in table 8. Contrary to their actual practice as indicated in table 6, 50 per cent of these mothers believed that infants aged three to six months thrived best on breast-feeding alone, while about 35 per cent shared the view that a combination of breast-and bottle-feeding was the right answer (table 8). There was some suggestive evidence from the studies that bottle-feeding was not very strongly or extensively promoted by the hospital/clinic staff attending these mothers, although quite a number of the women (22 per cent) claimed that they received free milk samples for an ill-defined period after delivery of their babies (tables 9 and 10).

TABLE 9. Encouragement to Bottle-feed

Mothers were asked whether they were encouraged to bottle-feed either by advice or by a gift of free feeding bottles from the hospital or clinic.

TABLE 10. Data on Gift of Free Milk Samples to Mothers after Delivery by the Hospitals

DISCUSSION AND RECOMMENDATIONS

Complex interactions between broad economic and socio-cultural factors influence infant-feeding practices in the developing countries The present study of infant-feeding practices and maternal attitudes involved 558 urban women, most of whom had little or no formal education, drawn mainly from the low-income level of Lagos society. The major variables investigated were the prevalence of breast-feeding and its duration, with or without supplementary feeding. Our data demonstrated quite convincingly that virtually all the mothers studied still entertained strong positive feelings about the importance of breast-feeding, an observation consistent with the reported findings of Goyea and Johnson (4) in a smaller number of Nigerian women residing in the ancient city of Benin, Bendel State.

Equally evident from the present study was the wide discrepancy between the actual infant-feeding practice of the women and their expressed views on what the practice ought to be (tables 5, 6, and 8). Quite often the actual practice fell short of the mother's nutritional awareness, thus contradicting the frequently repeated statements that such illiterate, urbanized women are victims of poor or improper counselling.

Results of the present study are consistent with reports (4-7) of progressive decline in the prevalence and duration of breast-feeding among urban Nigerians. It is noteworthy, however, that urban mothers retain their belief that "breast is best" and that despite the difficulties, over 98 per cent of mothers still manage to breast-feed for an average of two to three months. Most of these earlier reports attributed the negative change to attitudes and influences imported from the developed world and the preference for bottle-feeding by the urbanized African. It is clear that such explanations are oversimplified and apply to only a few and ignore the hard realities of urban existence that may make prolonged breast-feeding difficult. The crucial questions, as rightly pointed out by Harfouche (8), are why and how "women who migrate from the traditional rural areas to the so-called modern universe adjust to new situations, adopt new attitudes and patterns of behaviour."

For most Nigerians, urban existence is synonymous with extreme individual and community poverty. Implicit in this is a great pressure on mothers to spend more time trying to augment the family income at the expense of caring adequately for their children. There is good evidence from the present study that breast-feeding has not lost its prestige among the economically underprivileged labouring classes in metropolitan Lagos, but is accorded lower priority because of the overwhelming competing factors of urban existence resulting from poverty. The crucial issue is how to promote breast-feeding in the presence of the extensive poverty characteristic of urban life in many parts of the developing world. This issue assumes very serious dimensions in view of the relatively rapid urban growth rate (5 to 10 per cent) in these developing countries as exemplified by the disturbing projection that 50 per cent of the African population will be living in cities by the year 2000, a phenomenon that has rightly been described by United Nations demographers as "the greatest mass migration in human history" (9).

Findings in the present study were consistent with the view that childhood malnutrition is more a result of objective conditions of people's lives than ignorance on the mother's part (10). It is suggested that economic and social pressures under which the low-income group live in an urban area, rather than serious ignorance on the part of the women, were responsible for the critical change in traditional infant feeding practices and the African image of mothering. Until this major structural defect of urban life in the developing world is eliminated or controlled, any nutrition education programme that solely emphasizes and extols the virtues of breast-feeding, facts already well accepted by the people, is bound to achieve minimal results in terms of reversing the current trend towards increasing displacement of breast-feeding by bottle-feeding

Perhaps more lasting benefits will be achieved by emphasizing the education of mothers on how to prepare and use hygienically acceptable supplementary foods from relatively inexpensive but nutritious locally available staple foods. Too much educational effort has been spent on trying to teach impoverished, urbanized women precisely when to introduce supplementary feeding, when it is often forgotten that even among nutrition experts there is still lack of unanimity on this issue (11-14). Rather, concentration should be on how to do this most effectively. In addition, government policies in developing countries should address the severe poverty of urban immigrants that prevents them from being able to feed their children properly.

REFERENCES

1. "The Dynamics of Breast-feeding," WHO Chronic/e, 37: 6 (1983).

2. "Contemporary Patterns of Breast-feeding," report on the WHO Collaborative Study on Breast-Feeding (WHO, Geneva, 1981).

3. O.A. Darwish, E.K. Amine, and S.M. Abdulla, "Impact of Socio-economic Level on Infant Feeding Patterns in Iraq," Food Nutr. Bull., 5 (1): 16 (1983).

4. H.S. Goyea and E.J. Johnson, "Benin City Mothers: Their Beliefs concerning Infant Feeding and Child Care," Trop. Geogr. Med., 29: 103 (1977).

5. O. Alakija and F. Ukoli, "An Evaluation of Feeding Habits of Infants Seen at an Urban Health Centre in Benin City, Nigeria," Niger. Med., 19: 683 (1979).

6. J. Uyanga, "Rural-Urban Differences in Child Care and Breast Feeding Behaviour in South Eastern Nigeria," Social Sci. Med., 14: 23 (1980).

7. I. Owie, "Influence of Educational Attainment on Nigerian Mothers: Preference for Breast or Artificial Feeding for Infants," Pub. Hlth Rep., 95: 562 (19801.

8. J.K. Harfouche, "Psycho-social Aspects of Breast-feeding, Including Bonding," Food Nutr. Bull., 2 (1): 2 (1980).

9. K. Newland, "The City Limits: Emerging Constraints on Urban Growth" (Worldwatch Institute, Washington, D.C., 19801.

10. M. Segal and A. White, "Research on Primary Health Care: A Multidisciplinary Project in Ghana," Wrld. Hlth. Forum, 2: 341 (19811.

11. R.G. Whitehead, "The Infant Food Industry," Lancet, 1976 ii: 1192.

12. N.S. Scrimshaw and B.A. Underwood, "Timely and Appropriate Complementary Feeding of the Breast-fed Infant - An Overview," Food Nutr. Bull., 2 (2): 19 (1980).

13. W.R. Aykroyd, "Is Breast Feeding Best for All Infants Everywhere?" Nutr. Today, 12 (1): 15 (1977).

14. N.S. Scrimshaw, "Programs of Supplemental Feeding and Weaning Food Development," in N.S. Scrimshaw and M.B. Wallerstein, eds., Nutrition Policy Implementation-Issues and Experience (Plenum Press, New York, 1982), p. 101.

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