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Amin Salem Bredan, Suad Mohammed Bshiwah, and Nanduri Sampath Kumar
Introduction
Infant-feeding practices are influenced by sociocultural and economic factors [1, 2]. Breast-feeding, the virtues of which have been described adequately [3-6] remains the general rule in the Arab world, particularly among rural populations [7-9]. Bottle-feeding has been introduced, however, and is becoming widespread among higher socioeconomic groups [9, 10] and working mothers [8]. In at least one newly affluent Arab society, the number of women who breast-feed has suffered a catastrophic decline [11] Supplementation of the infant's diet with semi-solid foods, another important aspect of infant feeding, is generally delayed in Arab countries, especially in rural areas [8, 12], but it is practiced from the early months in some societies [7, 13].
Information about infant feeding in Libya is scanty but points to widespread adoption of bottle-feeding among educated urban mothers [14]. The present study was undertaken to investigate infant-feeding practices among urban Libyan women and to assess the influence of the mothers' education and employment.
Materials and methods
Three hundred pregnant women attending the outpatient gynecology department at the centrally located Zawiat Dahmani Polyclinic in Tripoli were screened, and expatriates and primiparas were excluded.
The remaining 212 multiparous Libyan mothers were interviewed to elicit the following information:
- for the mother: age, educational status, and employment; and
- for the previous child: duration of breast-feeding, age at which bottle-feeding was first introduced, reasons for introducing the bottle, and diet at age three months. If the most recent child was still breast-feeding or was under three months old, the data were obtained for the next youngest child. Responses that were vague or uncertain or that contradicted other responses were excluded from the results.
The data were analysed for the different education and employment groups. Student's t test was used to compare mean values, and chi-square was used to compare percentages.
Results
Sample
One-third (32.5%) of the mothers were illiterate, and another one-third (30.2%) had received a primary school education. The mean age was 32.2 years for the illiterate mothers, and declined with educational status to 26.5 years for those with a post-primary education (seventh grade or higher). Only one illiterate and one primary school mother were employed, in contrast to 38.0% of the mothers with post-primary education (table 1).
TABLE 1. Distribution of mothers by educational status, age, and employment
No. |
% of total |
Mean age (yrs) |
Employed |
||
No. |
% |
||||
| Illiterate | 69 |
32.5 |
32.2 |
1 |
1.4 |
| Primary | 64 |
30.2 |
27.8 |
1 |
1.6 |
| Post-primary | 79 |
37.3 |
26.5 |
30 |
38.0 |
| Total | 212 |
100.0 |
28.9 |
32 |
15.1 |
General feeding patterns
The great majority (95.6%) of the infants were breast-fed for varying periods of time (table 2): 44.6% for 5 months, and 25.1% for 6 to 12 months. The mean weaning age was 8.8 months (table 3).
TABLE 2. Prevalence of bottle-, breast-, and mixed feeding by educational status of mother
No. |
Breast (%) |
Bottle (%) |
Mixed (%) |
|
| Illiterate | 68 |
27 9(a) |
1.5(b) |
70.6 |
| Primary | 62 |
16.1 |
1.6 |
82.2 |
| Post-primary | 74 |
12.2(a) |
9 9.5(b) |
78.4 |
| Total | 204 |
18.6 |
4.4 |
77.0 |
a. p < .05. b. < .01.
Breast-feeding and bottle-feeding were practiced exclusively by 18.6% and 4.4% of mothers respectively, while 77.0% practiced mixed feeding. The mean age at initiation of bottle-feeding for the infants fed only by bottle (after breast-feeding was stopped) and those fed by mixed methods was 2.9 months (table 4).
The major reason cited for initiating bottle-feeding was inadequacy of milk (55.9%), followed by the infant's refusal to nurse (16.8%) (table 5).
TABLE 5. Reasons given for introducing the bottle, by educational status and employment of mother (percentages)
Illiterate (N = 43) |
Primary (N = 42) |
Post-primary (N = 58) |
Total |
|
| Inadequate milk | 53.5 |
66.7 |
50.0 |
55.9 |
| Infant's refusal to nurse | 14.0 |
14.3 |
20.7 |
16.8 |
| Breast or nipple condition | 7.0 |
4.8 |
12.1 |
8.4 |
| Absence or illness of mother | 4.7 |
9.5 |
6.9 |
7.0 |
| Pregnancy | 9.3 |
9.5 |
6.9 |
8.4 |
| Weaning | 4.7 |
7.1 |
3.4 |
4.9 |
| Convenience | 7.0 |
2.4 |
3.4 |
4.2 |
Feeding patterns at three months of age
At three months of age, 46.4% of the infants were exclusively breast-fed, 27.0% were exclusively bottlefed, and 26.5% were fed by mixed methods. Supplementation with cereals, vegetables, fruits, or a combination of these was practiced by 63.2% of mothers. The most commonly used supplement was cereal, which was given to 54.5% of the infants. Eggs and ground almonds mixed with honey were administered in small amounts to 29.9% and 21.3% of the infants respectively.
TABLE 6. Dietary items feed, alone or in combination, to most recent child at three months of age, by educational status of mother (percentages)
| Illiterate (N = 70) | Primary (N = 64) | Post-pnmary (N = 77) | Total (N = 211) | |
| Breast | 54.3 | 42.3 | 42.9 | 46.4 |
| Bottle | 17.1a | 26.6 | 36 4a | 27.0 |
| Breast and bottle | 28.6 | 31.3 | 20.8 | 26.5 |
| Supplement | ||||
| cereal | 52.9 | 65.6 | 46.8 | 54.5 |
| vegetables | 21.4a | 25.0 | 39.0a | 28.9 |
| fruit | 14.3 | 21.9 | 22.1 | 19.4 |
| eggs | 27.1 | 29.7 | 32.5 | 29.9 |
| almonds | 20.0 | 26.6 | 18.2 | 21.3 |
a.p<.05.
Socioeconomic comparisons
The illiterate mothers practiced breast-feeding for a significantly longer time, 12.6 months, than those with post-primary education, 5.7 months (p < .001). In the latter group, even the unemployed mothers breast-fed their infantis for a shorter duration, 6.3 months, than their illiterate counterparts, 12.8 months (p<.001).
The reverse trend was observed among the mothers who bottle-fed exclusively - 1.5%% of the illiterate mothers and 9.5% of those with post-primary schooling (p<.01): the percentages of these mothers who only bottle-fed when their infants were three months old were 17.1 and 36.4 respectively (p<.05). Supplementation of the infant's diet with vegetables at three months of age was more common among mothers with post-primary education (39.0%) than among illiterate mothers (21.4%) (p < .05).
Discussion
A review of the literature on breast-feeding patterns in the eastern Mediterranean region [12] observed the adoption of attitudes that have a negative effect on breast-feeding, and a decline in its prevalence and duration, mainly in urban areas and among educated mothers. We found that it was still widespread among urban Libyan women, 95.6% of whom breast-fed their infants for varying periods of time. This rate is similar to that in one report, 90% [15], but is higher than that noted in another, 68% [14]. The percentage of the mothers in the present study who practiced exclusive bottle-feeding, 4.4, however, cannot be reconciled with the 31.8% reported elsewhere [14] That study also observed a much lower rate of mixed feeding, 26.1%, than we did, 77.0%. It is doubtful that differences of this magnitude represent a time-related trend.
In spite of the widespread practice of breast-feeding (95.6%) and its moderately long duration (mean 8.8 months), artificial feeding was practiced by 81.4% of the mothers, resulting in a pattern of mixed feeding (bottle with breast or bottle after breast) for 77.0%. Although the most common reason cited for introducing the bottle was inadequacy of milk, it is unlikely that all these cases represent real quantitative or qualitative deficiencies in the milk supply. More likely, many women may adopt artificial feeding out of an unjustified fear that their infant is not receiving sufficient nourishment, or from a desire to fatten the child. Furthermore, a number of factors may contribute to unsuccessful lactation, including inadequate knowledge of the proper procedure for establishing lactation, hospital practices delaying the first feedings and separating mother from infant, and the psychological impact of the availability of a wide variety of infant formulas [12].
Education was found to have a significant negative influence on both the prevalence and the duration of breast-feeding. Similar trends have been observed in Bahrain [9, 10]. In view of the increasing education and employment of Libyan women, the practice of breast-feeding may still be declining. In terms of the categories suggested by Jelliffe [16] and Pellet [17], urban Libyan women may be classified as uneducated bottle-feeders, although they may be moving toward the category of elite bottle-feeders.
The consequences of artificial feeding as practiced by mothers ignorant of elementary hygiene include gastroenteritis and marasmus [17]. Despite the high per capita income in Bahrain, a significant association was found between symptomatic cholera infection and a history of being principally bottle-fed [18], and in Kuwait the major cause of death in children below two years of age was reported to be gastroenteritis [13].
It has been suggested [19, 20] that breast milk alone is insufficient to meet the nutritional needs of infants after the age of three months. Others, however, have observed that breast milk alone is sufficient up to the age of six months, provided that both the mother and the infant are in good health and that the infant's growth is monitored [21]. In either event, the majority of urban infants in Libya do not appear to be at risk of delayed supplementation, as only 27.8% received no supplementation at three months of age. Supplementation may be related to the socioeconomic development of the country, as it has been reported to be introduced early in Bahrain [10] and Kuwait [13], but to be delayed in Egypt [8] and to represent the major nutritional problem of infant feeding in poor rural areas in Sudan [22].
Acknowledgement
We thank Dr. A. Khalifi of the Zawiat Dahmani Polyclinic and Dr. A. M. Doughri of the National Academy for Scientific Research, Tripoli, for their co-operation and assistance.
References