Breast-feeding practices and maternal employment in health facilities of Lira District, Northern Uganda

In Uganda, many working mothers stop breast-feeding before the end of the mandatory maternity leave of 60 days. Inadequate breast-feeding is a risk factor for infant morbidity and mortality. Thus, understanding of the factors that influence breast-feeding is essential so as to advocate for the appropriate breast-feeding practices. This cross-sectional study assessed the pre-lacteal feeding (PLF), early initiation of breast-feeding (EIBF) and exclusive breast-feeding (EBF) and the associated factors for PLF, EIBF and EBF among working mothers in health facilities in Lira District, Northern Uganda. Among 376 mothers who participated, the prevalence of PLF, EIBF and EBF was 23.2%, 67.0% and 43.9%, respectively. Mode of delivery was significantly associated with PLF (AOR = 0.39, 95% CI 0.22–0.68, p < 0.01), while mode of delivery (AOR = 3.77, 95% CI 2.19–6.47, p < 0.01), length of daily working time (AOR = 0.49, 95% CI 0.29–0.82, p < 0.01) and paid maternity leave (AOR = 0.45, 95% CI 0.22–0.95, p < 0.05) were the statistically significant factors associated with EIBF. Age-group, income level, mode of delivery (AOR = 0.26, 95% CI 0.09–0.74, p < 0.05), distance to workplace (AOR = 0.45, 95% CI 0.26–0.78, p < 0.01), paid maternity leave (AOR = 0.45, 95% CI 0.22–0.95, p < 0.01), breast-feeding space (AOR = 0.30, 95% CI 0.16–0.59, p < 0.05) and breast-feeding break (AOR = 0.84, 95% CI 0.47–1.50, p < 0.01) were the significant factors associated with EBF. Exclusive breast-feeding and pre-lacteal feeding among working mothers in health facilities in Lira District are lower than the national averages, but prevalence of early initiation of breast-feeding is higher than the national average.


Background
Breast-feeding practices are activities that mothers undertake to feed their infants. Pre-lacteal feeding (PLF), early initiation of breast-feeding (EIBF) and exclusive breast-feeding (EBF) are some of the common breastfeeding practices (WHO 2018). PLF, practiced to varying degrees across the globe, is the act of giving fluid or semisolid foods to an infant before initiation of breast-feeding during the first 3 days after birth (Talbert et al. 2018). On the other hand, EIBF is the initiation of breast-feeding within 1 hour of birth (UNICEF 2018). The WHO expounds EBF as a breast-feeding practice wherein the infant in the first 6 months receive only breast milk and no other liquids or solids (not even water), with the exception of oral rehydration solution, syrups, minerals or medicines (WHO 2018).
Inadequate breast-feeding is a risk factor for infant morbidity and mortality. However, it is challenging for employed mothers to practice EBF (Tadesse et al. 2019). In Uganda, many working mothers stop breast-feeding before the end of the mandatory maternity leave of 60 days. The Ugandan government and other stakeholders have strived to improve EBF (Clara 2018), but breastfeeding practices in the war-torn Lango subregion where Lira District is located have remained suboptimal (Napyo et al. 2020;UBOS 2018). The aim of this study was therefore to assess breast-feeding practices (PLF, EIBF and EBF) and the associated factors among working mothers in some health facilities of Lira District, Northern Uganda.

Methods
This study is reported following STrengthening the Reporting of OBservational studies in Epidemiology (STROBE) guidelines (Additional file 1: Table S1).

Study area and participants
This study was conducted in Lira District (2°14′59.6"N 32°53′59.5"E) in Lango subregion of Northern Uganda. It is approximately 342 km North of Kampala (Uganda's capital) by road. All other districts in the subregion were carved out of Lira which was originally Lango District. The district share frontiers with Agago and Pader districts to the North, Otuke and Alebtong to the East, Dokolo to the South, Apac and Kwania to the Southwest, and Kole and Oyam to the West. The total population of the district is 408,043, out of which 211,380 (51.8%) are females and 196,663 (48.2%) are males (UBOS 2017). Most women in formal employment in Lira are employed in educational institutions, health facilities and commercial institutions.

Study design and study population
This study was a cross-sectional study which targeted working mothers in 36 health facilities across Lira District. Mothers with infants less than 6 months of age and were living and working in health facilities in the district for over 2 years were the source population.

Inclusion and exclusion criteria
The study included mothers of 18 years and above who have been resident in Lira District for the last 2 years, are formally employed in government or private health facilities, have a biological child below 6 months old, are fluent in English language and were willing to participate in the study. Non-biological, seriously ill mothers (with medical reasons for not breast-feeding), non-consenting mothers and mothers unable to communicate due to hearing loss were excluded from the study.
Based on the proportion of government (52%) versus private (48%) facilities, 19 government and 17 private facilities (out of 48 health facilities) were chosen (Additional file 2: Table S2). Participants were selected by simple random sampling. (199 and 183 participants were selected from government and private health facilities, respectively.)

Breast-feeding
Feeding of an infant or young child with breast milk either directly from human breasts by suckling or by expressed breast milk.

Early initiation of breast-feeding
Initiating breast-feeding within the first hour of birth.

Pre-lacteal feeding
Cultural practice of giving a newly born child any fluid or semisolid food such as water, black tea, honey, sugar solution, herbal paste, and so forth, before initiating breastfeeding, usually lasting for the first 3 days after delivery.

Exclusive breast-feeding
Mother breast-fed and no other liquids or solids were given, to the child aged less than 6 months in the 24 h prior to the survey, with the exception of oral rehydration solution, supplements or medicines (Adugna et al. 2017).

Continued breast-feeding
The feeding process starting when breast milk alone is no longer sufficient to meet the nutritional requirements of infants, and therefore other foods and liquids are needed, along with breast milk.

Working mother
Mother who is formally employed either by government or by non-government organization on full-time or parttime basis, where the employer has the power or right to control and direct the working mother on how the work is to be performed.

Partial breast-feeding
Giving a baby some breast-feeds, and some artificial feeds, either milk or cereal, or other food (Adugna et al. 2017).

Seriously ill mothers
Working mothers who are either unconscious, unable to give the required information for this study or have medical reasons for not breast-feeding.

Conceptual framework and study measurement of variables
Breast-feeding practices are a product of several factors which influence a woman's decision to breast-feed or not. The relationship between these factors and how they influence breast-feeding practices is shown in the Conceptual Framework used in this study (Fig. 1).
The dependent variables in this study were the breastfeeding practices, which were measured in terms of giving of pre-lacteal feeds, early initiation of breast-feeding (within 1 hour postpartum) and exclusive breast-feeding for 6 months. These breast-feeding practices are influenced by socio-demographic, work-related as well as obstetric factors which contribute to a woman's decision to breast-feed. The independent variables were the predictors of breast-feeding practices. These were measured in terms of socio-demographic, work-related and obstetric factors which influence breast-feeding practices. Socio-demographic factors such as mother's age, level of education, marital status, number of children and income level are believed to influence a mother's decision to breast-feed or not. Work-related factors such as type of employer, length of daily working time, provision of paid maternity leave, workplace breast-feeding policies such as provision of breast-feeding breaks and space for breast-feeding influence the breast-feeding practices of the working mothers. Furthermore, obstetric factors such as number of antenatal visits, receiving breast-feeding counselling, place and type of delivery influence the breast-feeding practices adopted by working mothers.
Knowledge and attitude of mothers regarding breastfeeding are the mediating variables in this study. They strengthen or weaken the influence of the predictors of breast-feeding (socio-demographic, work-related and obstetric factors) on breast-feeding practices. Good knowledge about breast-feeding and a positive attitude of mothers improve the likelihood of them adopting good breast-feeding practices and vice versa.

Data collection
Data were collected by trained research assistants using a pretested interviewer-administered questionnaire in English. The questions were constructed based on previous studies (Napyo et al. 2020). The questionnaire had socio-demographic variables and breast-feeding practices: PLF, EIBF and EBF.

Data analysis
Data were manually checked, coded and entered in Stata 15 (StataCorp, College Station, Texas, USA). Descriptive statistics were then used to summarize the data (Napyo et al. 2020). Association between socio-demographic characteristics, work-related and obstetric factors was investigated using chi-square test.
Variables that were significantly associated were considered for multivariate logistic regression (at p < 0.05) to determine the potential predictors of breast-feeding practices.

Results
By the end of the study, a response rate of 98.43% by the participants was realized.
Most respondents had two children or more (67.82%).

Breast-feeding practices among working mothers
PLF was practiced by 23.2% of the respondents using sugar/glucose solution, warm water, animal milk, honey syrup, black tea and passion juice (Table 2). On the other hand, EIBF was practiced by 67.0% of the mothers, while EBF was practiced by 43.9% of the respondents.

Socio-demographic factors
Only age-group and income level were found to be statistically significant factors associated with breast-feeding practices in Lira health facilities (Tables 3, 4, 5, 6). Age-group of 31-40 (AOR = 2.22, CI = 1.28-3.85) or 41 and above (AOR = 6.93, CI = 1.76 -27.2) had very high odds and were more likely to practice EBF compared to the 18-30 group (Table 4). For income level, there were reduced odds of EBF among working mothers with increasing income level. Working mothers who earned between UgX 1,000,001 and 1,500,000 were less likely

Work-related factors
Length of daily working time, distance to workplace, paid maternity leave, breast-feeding space and daily breastfeeding break were statistically significant at multivariate analysis. Mothers who worked for more than 8 h (AOR = 0.49, 95% CI 0.29-0.82) were 0.49 times less likely to initiate breast-feeding early as compared to those who worked for less than 8 h. This implies that working for longer hours is a big hindrance to EIBF (Tables 4,  5). With respect to distance to workplace, mothers who traveled 2-5 km to their workplaces (AOR = 0.45, 95% CI 0.26-0.78) were found to be 0.45 times less likely to practice EBF compared to their counterparts who traveled less than 2 km (Tables 4, 6). Mothers who did not get paid maternity leave (AOR = 0.45, 95% CI 0.22-0.95) were less likely to practice EIBF but EBF. Mothers who reported lack of breast-feeding space (AOR = 0.30, 95% CI 0.16-0.59) and no breast-feeding break at workplace (AOR = 0.84, 95% CI 0.47-1.50) had significantly lower odds of EBF.

Discussion
Among the 376 mothers who participated in the study, the prevalence of PLF, EIBF and EBF was 23.2%, 67.0% and 43.9%, respectively. Mode of delivery was significantly associated with PLF, while mode of delivery, length of daily working time and paid maternity leave were the statistically significant factors associated with EIBF. Age-group, income level, mode of delivery, distance to workplace, paid maternity leave, breastfeeding space and breast-feeding break were the significant factors associated with EBF. The majority of the respondents in this study were married, within 18-30 years of age, holding diploma and earnings between Uganda shillings (UgX) 1 and 500,000 per month. Most respondents had two children and above (67.82%) which indicates that the majority of women employed in the health facilities in Lira are still in reproductive age. These statistics agree with previous reports in Lira District (Mukunya et al. 2019;Napyo et al. 2020).
PLF was practiced by 23.2% of the respondents using sugar/glucose solution, warm water, animal milk, honey syrup, black tea and passion juice. This corroborates a previous report in Lira District (Mukunya et al. 2017). This prevalence rate is higher than 12.7% previously reported for HIV-exposed infants in Lira (Napyo et al. 2020) but lower than 25.1% for Lango subregion, the national average of 26.6% (UBOS 2018) and 32.2% for some countries in the Sub-Sahara (Berde & Ozcebe 2017). This could be due to good knowledge and awareness of the dangers of PLF by the respondents, who are health workers. PLF is not a good practice and has been shown to delay the initiation of breast-feeding, interferes with EBF and increases the risk of illness, stunting, hospitalization and mortality in newborns (Chea & Asefa 2018;Mengistu et al. 2013;Nguyen et al. 2020). It is also important that cultural beliefs also influence infant breast-feeding practices, especially PLF (Abie & Goshu 2019), for example, believing that giving babies honey protect them against false teeth and colic pain (Mukunya et al. 2019).  On the other hand, EIBF was practiced by 67.02% of the mothers, which is higher than that of Lango subregion (44.8%), the national average (66.1%) (UBOS 2018) but lower than 76.8%, 78.8% and 73.1% previously reported in Ethiopia (Abie & Goshu 2019;Bimerew et al. 2016;Tewabe 2016). This is a good indicator of optimal infant and young child feeding among working mothers in Lira District. A meta-analysis report for Sub-Saharan countries showed that EIBF prevalence varied from 37.84% in Central Africa to 69.31% in Southern Africa, while Eastern Africa stood at 61.82% (Issaka et al. 2017). WHO report (WHO 2017a) indicated that the global prevalence of EIBF is 49%, with the highest in Italy (94%) and lowest in Saudi Arabia (23%). The high prevalence of EIBF in this study could be attributed to the better understanding of the recommended breast-feeding practices among working mothers who were health workers and had positive attitude toward breast-feeding. Further, most participants were young mothers. Previous studies indicate that elder mothers are less likely to practice EIBF (Abie & Goshu 2019). These attributes could be exploited by the healthcare system to further improve EIBF among breast-feeding mothers outside formal employment in Lira and beyond. EIBF confers various benefits, including increased immunity, reduced risk of diarrhea and decreased infant mortality (Abie & Goshu 2019;Lawrence & Lawrence 2016;Mugadza et al. 2018;UNICEF 2018;WHO 2017b).
EBF was practiced by 43.09% of the respondents, indicating that its prevalence among the working mothers is higher than previously reported for HIV-exposed infants in the district (42.9%) (Napyo et al. 2020) but lower than the national average of 66% (UBOS 2018) and the global target of 70% (UNICEF 2018). This is a likely contributor to under-feeding of infants and young children which may result into higher child morbidity and mortality. Chhetri et al. (Chhetri et al. 2018) reported EBF prevalence of 17.5% among working mothers in Udupi taluk of India. Another study (Tadesse et al. 2019) in Ethiopia reported EBF prevalence of 24.8% among mothers. These findings are corroborated by the present study.
This study revealed that only age-group and income level were statistically significant factors associated with breast-feeding practices in Lira health facilities. Specifically, the age-group of 31-40 or 41 and above had high odds and were more likely to practice EBF compared to the 18-30 group. This implies that older mothers are more likely to practice EBF than the younger ones, which corroborates previous reports in Uganda (UBOS 2018), Malawi and Zimbabwe (Chipojola et al. 2020) and Bangladesh (Agho et al. 2021). For income level, reduced odds of EBF were evident among working mothers with increasing income level. Working mothers who earned more money were less likely to practice EBF probably because of the ability of high-income earners to easily afford breast milk substitutes. This agrees with a previous report in Uganda (UBOS 2018) and Ghana (Mensah et al. 2017).
For obstetric factors, normal delivery was significantly associated with PLF (AOR = 0.39, 95% CI 0.22-0.68), EIBF (AOR = 3.77, 95% CI 2.19-6.47) and EBF (AOR = 0.26, 95% CI 0.09-0.74). Mothers who delivered normally tended to not practice PLF and EBF but were more likely to practice EIBF compared to those who delivered by caesarean section. This report is congruent with a report from Turkey (Yılmaz et al. 2017) but contrary to a report from Ethiopia (Adugna et al. 2017).
For work-related factors, the length of daily working time, distance to workplace, paid maternity leave, breast-feeding space and daily breast-feeding break were statistically significant at multivariate analysis. Mothers who worked for more than 8 h were less likely to    initiate EBF, indicating that working for longer hours is a big hindrance to EIBF. This finding agrees with that of Snyder et al. (2018) who reported that women who work for long hours need more workplace support to improve their breast-feeding practices. With respect to distance to workplace, mothers who traveled longer distances to their workplaces were less likely capable of practicing EBF. This points that long distance to the place of work is a barrier to EBF since working mothers are more likely to leave their babies at home as they work. Similarly, mothers who did not get paid maternity leave were less likely to practice EIBF but EBF. This is contrary to findings from other studies which reported that the absence of paid maternity leave reduces the odds of EBF among working mothers (Snyder et al. 2018). Paid maternity leave avails opportunity to working mothers to stay longer with their babies and increases the likelihood of practicing EBF. Mothers who reported lack of breast-feeding space and no breast-feeding break had significantly lower odds of EBF. Indeed, presence of a designated space where working mothers can conveniently breast-feed and provision of daily breast-feeding breaks are good incentives for working mothers to practice EBF (Lauer et al. 2019).

Study limitations
This study had some limitations. Though both government-owned and private health facilities were included in this study, some health facilities were excluded. Secondly, we recognize that even if this study sampled participants from households, there would have been some who were working and others not. Such data would have provided a better comparison than this study have done. Lastly, the questionnaire survey used is prone to recall bias. To overcome this, respondents were allowed sufficient time to reflect on the questions before responding. Data collectors were also trained to acquire best skills of data collection to improve the accuracy and volume of data compiled.