Evaluation of Mothers’ Knowledge, Attitudes, and PracticeTowards the Ten Steps to Successful Breastfeeding in Egypt

Azza M.A.M. Abul-Fadl,1 Maissa Shawky,2 Amal El-Taweel,3 Karin Cadwell,4 and Cynthia Turner-Maffei5

Abstract

Background: Despite the proven effectiveness of the Ten Steps to Successful Breastfeeding of the Baby-FriendlyHospital Initiative (BFHI), its impact on community practices in Egypt has yet to be assessed. The aim of thisinvestigation was to evaluate the knowledge, attitudes, and practice (KAP) of Egyptian mothers towards the TenSteps. We interviewed 1,052 breastfeeding mothers with infants less than 24 months of age from 12 governoratesrepresenting Upper Egypt (UE) and Lower Egypt (LE).Results: Marked regional variations are noted in the KAP of the samples from UE and LE. These differences canbe explained to some extent by socioeconomic factors. Hospital delivery, lower parity, and a higher level ofeducation were characteristic of mothers in LE compared with UE. More mothers in UE did not know about theprotective effects of breastfeeding to the mother. In LE, 75% delayed breastfeeding initiation until after the firsthour compared with 61% in UE, with the mothers reporting that they did not experience skin-to-skin care in thefirst hours after birth. Nipple pain was given as a cause for supplementation in 56% of mothers in UE and 36% inLE ( p < 0.001). Maintaining milk by expression is practiced by 42.8% of mothers in LE and 12% in UE. Two-thirdsof the mothers in both UE and LE offer herbal drinks, and one-third feed infant milk formula before 6 months.Offering pacifiers is more common in LE, and feeding by bottle is more common in UE, being pressured by themother’s social network.Conclusions: To increase the impact of BFHI on community breastfeeding practices, BFHI should focus oninvolving the family members with the mother throughout the implementation of the Ten Steps while en-couraging maternal support groups and taking cultural differences into account.

Introduction

The Baby-Friendly Hospital Initiative (BFHI) was in-troduced by UNICEF/World Health Organization

(WHO) through the Innocenti Declaration in 1991 and revisedin 2006; health facilities are urged to change their maternitycare practices to become more supportive of breastfeedingbased on the Ten Steps to Successful Breastfeeding.1 Over thepast two decades evidence-based medical research has shownthe effectiveness of the Ten Steps in reversal of neonatalmorbidity and mortality rates from common infectious dis-eases and disabilities that were closely linked to practices thatdisrupt breastfeeding.2,3 Social and economic benefits havealso been shown by implementation of the BFHI in both de-veloped and developing countries. The widespread success of

the BFHI, with its proven efficacy as one of the most effectiveand least costly interventions, has driven the UNICEF andWHO to call for its revival through a 2006 update for ex-pansion and a recommendation that it become integratedinto the WHO Global Strategy for Infant and Young ChildFeeding.4,5

Assessment of knowledge, attitudes, and practices (KAP)of mothers is one way to identify high-risk areas and popu-lations in need. This can help to target interventions appro-priately, especially when resources are limited. Over the pastdecade, BFHI implementation has declined in Egypt, andbreastfeeding promotion activities were subsumed into theWHO Integrated Management of Childhood Illness pro-grams. As Egypt now turns to revive BFHI, previous strate-gies need to be revised as new evidence-based strategies

1Department of Pediatrics, Benha Faculty of Medicine, Benha University, Kaluibiya, Egypt.2Cairo Medical Faculty, Cairo University, Cairo, Egypt.3Egyptian Lactation Consultant Association, Cairo, Egypt.4Healthy Children Project, Inc., East Sandwich, Massachusetts.5The Union Institute & University, Cincinnati, Ohio.All the authors contributed equally to this work.

BREASTFEEDING MEDICINEVolume 7, Number 3, 2012ª Mary Ann Liebert, Inc.DOI: 10.1089/bfm.2011.0028

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emerge. Assessment of the needs of mothers in Upper andLower Egypt (UE and LE, respectively) would be helpful inthis respect, especially since the Egypt Demographic HealthSurveys show that there are distinct ecological and socialdifferences between these regions, with significantly in-creased rates of poverty in UE.6 Hence the aim of this work isto study and analyze the KAP of mothers towards practicesrelated to the Ten Steps of the BFHI in a representative sampleof the country.

Subjects and Methods

This is a cross-sectional descriptive study that was con-ducted by interviewing 1,052 mothers who were breastfeed-ing infants less than 24 months of age selected from 12governorates: five in UE and five in LE and the two majorurban governorates of Cairo and Alexandria located in LE.Data were collected in the interval of January–May 2008. Thelogistics included receiving permission from the central aswell as the governorate health offices of the directorates vis-ited. The work was conducted by local as well as centrallyrecruited interviewers. The tools used were questionnairesthat were locally prepared and adapted and tested. The in-terviews were conducted one to one, face to face, compiled bythe interviewer, and sent to the researchers.

Ethical considerations were taken into consideration. Themothers participated anonymously and gave informed con-sent for participation and to use their responses. They weremade aware that the information collected would be used todevelop and improve on the breastfeeding promotionalmessages and campaigns so that more mothers couldbreastfeed successfully.

Sample characteristics

Surveys were conducted and information was collectedfrom a convenience sample of 1,052 mothers recruited fromMaternal Child Health Clinics with breastfeeding babieswhose ages ranged between 6 weeks to 24 months. Fivehundred eleven mothers from LE and 541 from UE completedthe interviews. The LE governorates included Alexandria(n = 77), Beheira (n = 155), Cairo, (n = 72), Dakhlia (n = 99),Dameitta (n = 43), Ismailia (n = 60), and Port Saed (n = 5), to-taling 511 mother–infant pairs. The UE governorates includedAssiut (n = 110), Aswan (n = 217), Luxor (n = 40), Qena (n = 84),and Sohag (n = 90), totalling 541 mother–infant pairs.

Data entry and statistical analysis

Data were entered on Excel (Microsoft, Redmond, WA)sheets, coded, and revised for consistency. The StatisticalPackage for Social Science (SPSS�) version 13 (SPSS, Inc.,Chicago, IL) was used for the analysis. Mean, mode, median,and SD were used for continuous numerical values. Valueswere estimated for v2 tests (Fisher’s exact test was appliedwhenever tested values were below 5).

Results

Demographic profile

Most of the mothers interviewed lived in urban areas(61.7%), whereas only 30.2% came from rural areas and 8.1%from slum areas. Half of the mothers (53%) had received at

least 9 years of education, whereas 34.2% had received no orlittle education. The majority gave their occupation ashousewives (62.2%); working mothers made up 37.8% of thesurvey population, whereas 2.3% of mothers worked withoutpay.

Parity

Worldwide, mothers with higher levels of education tendto have fewer children. That was true in our survey popula-tion as well. The highest parity was seen among those withminimal or no education (19.5%), whereas those with highereducational level reported the smallest family size (fewer thanthree children).

Delivery practices

Fifty-seven percent of the mothers in the UE sample de-livered their babies in hospitals compared with 71.5% in LE.Only 11.1% of the mothers in UE gave birth via cesareansection compared with 20% in LE. Normal vaginal deliveryoccurred in 88.9% of deliveries in UE and 79.6% in LE.

KAP towards Ten Steps

Step 3 of the BFHI relates to prenatal education of themother and urges health workers to inform pregnant womenabout the benefits of breastfeeding. Table 1 shows that there isa significant difference in the knowledge of the mothers aboutthe benefits of breastfeeding between UE and LE. LE motherstend to have more knowledge about the protective effects ofbreastfeeding for the mother and child, whereas a signifi-cantly lower percentage of mothers in UE knows about theprotective effects of breastfeeding, particularly against breastcancer. The lowest level of knowledge is about the potentialcontraceptive effect of exclusive breastfeeding, particularlyamong the mothers interviewed in UE. Less than one-third ofthe mothers in UE and one-half of those in LE report theyknow how to use breastfeeding as a method of contraceptionin the first 6 months. Table 2 shows that less than one-half ofthe mothers know about the benefits of skin-to-skin care; thiswas significantly lower among mothers of UE, particularlywith regard to its effect on weight gain and breathing. Suchfindings indicate that Step 3 needs to be adequately im-plemented in both UE and LE.

Figure 1 shows that early initiation of breastfeeding (Step 4of the BFHI) is significantly delayed more in LE as three-quarters of the mothers do not initiate breastfeeding until afterthe first hour. This is compared with about 39% of mothers in

Table 1. Percentage Distribution of Mothers

Regarding Their Knowledge About the Value

of Breastfeeding in Upper Egypt Versus Lower Egypt

Geographical site

Knowledge about breastfeedingbenefits

LowerEgypt

UpperEgypt p value

Protects children from disease 64.9 60.8 0.0001Protects mothers from cancer 61.5 38.8 0.0001Can be used as a method

of contraception49.3 30.7 0.0001

174 ABUL-FADL ET AL.

UE who initiate breastfeeding in the first hour. Early initiationthrough skin-to-skin contact was poorly implemented in bothUE and LE. However, this is more prevalent among mothersin the middle age group (20–40 years old) compared with veryyoung ( < 20 years old) and older ( > 40 years old) mothers. Thedifference was significant at p < 0.006.

Lactation management issues and assuring an adequatemilk supply are included in Step 5 of the BFHI. Nipple pain isreported as a cause for supplementation in 56% of mothers inUE and 36% in LE ( p < 0.001). Expression of milk is practicedas a method to increase or maintain milk supply by 42.8% ofmothers in LE compared with only 12% in UE. More mothersin LE report that the best ways to increase milk supply was toincrease fluid intake (91.3%), to eat certain types of foods(82%), and to increase frequency of breastfeeding (71.9%)compared with mothers in UE (76.6%, 73.4%, and 69.4%, re-spectively) ( p < 0.001).

KAP related to avoiding unnecessary supplements (Step 6of the BFHI) shows that two-thirds of the mothers in both UEand LE introduce herbal drinks or decoctions to their babies inthe first 6 months. One-third of the mothers in both UE and LEgive infant milk formula before their babies are 6 months old.More mothers in LE believe that infants need foods before theage of 6 months (63% in LE compared with 43% in UE). The

source of information of mothers about formula and babyfood is from relatives and friends, followed by media, with theleast from health workers. More mothers in the extremes ofage ( > 40 years and < 20 years old) gave decoctions.

Rooming-in (Step 7) is practiced by almost all mothers inboth LE and UE (87.6% and 83.5%, respectively). On-demandfeeding (Step 8) occurs in 78.9% and 76.3% of births in LE andUE, respectively ( p < 0.03). Most mothers (95%) breastfeedtheir babies during the night. About 75.5% of the mothers inLE and 79.3% of mothers in UE believe that night feeding isuseful ( p < 0.002).

Step 9 of the BFHI seeks to limit the use of artificial teats andpacifiers; however, a large proportion of mothers (43.2% in LEand 39.2% in UE) report offering pacifiers to their babies. Mostof these mothers believe that these pacifiers are the best way tosoothe the baby. In two-thirds of the cases a relative is the onewho provided the mother with the advice to use a pacifier.Many mothers described carrying the baby as a better way tosoothe the baby than to give him or her a pacifier; however,mothers in LE were more knowledgeable than UE mothers inthis regard (80.8% in LE compared with 71.6% in UE;p < 0.001). More than half of the mothers in LE (55%) know thenegative effect of pacifiers on breastfeeding compared with40.4% in UE ( p < 0.001).

Table 3 shows that the use of bottles is more common thanpacifiers, as over one-half of mothers use a bottle to feed theirbaby (56.8% in UE and somewhat less in LE [51.9%]). Thismay be because almost two-thirds (60.5%) of the mothers in-terviewed in UE think that babies cannot feed away from thebreast except by a bottle, compared with only one-third in LE(39.2%). The difference is statistically significant at p < 0.001.Also, more mothers in LE (66%) than in LE (44%) know thenegative effects of bottles on breastfeeding ( p < 0.0001). The

Table 2. Percentage Distribution of Mothers

with Knowledge About the Various Benefits

of Skin-to-Skin Contact in Lower Egypt

Versus Upper Egypt

Geographical site

Benefits of skin-to-skin contactLowerEgypt

UpperEgypt p value

Provides warmth for the baby 54.8 47.6 0.000Promotes growth of baby 43.1 40.8 0.000Promotes weight gain 35.9 26.2 0.000Better breathing 38.1 26.4 0.000Better quality of sleep 50.0 44.4 0.000Less crying 60.2 49.9 0.000Supports breastfeeding 52.7 54.5 0.000

0

10

20

30

40

50

60

70

80

Immediately Within 1-3 hrs >3 hrs

Lower Egypt

Upper Egypt

FIG. 1. Percentage of timely initiation of breastfeeding inthe early postpartum period in Upper Egypt versus LowerEgypt.

Table 3. Percentage Distribution of the Knowledge,

Attitudes, and Practices of Breastfeeding

Mothers Toward Pacifiers and Feeding Bottles

in Lower Egypt Versus Upper Egypt

Geographical site

KAP for pacifiers and bottlesLowerEgypt

UpperEgypt p value

Mother gave her baby a pacifier 43.2 39.4 0.2Thinks pacifier calms her baby 44.0 47.2 0.3A relative provided a pacifier 63.4 64.2 0.05Knows that carrying the baby

is better than providinga pacifier

80.8 71.6 0.001

Mother carried the baby insteadof giving a pacifier

77.6 66.5 0.003

Mother used a bottle for feeding 51.9 56.8 0.2Thought that a baby cannot drink

except with a bottle39.2 60.5 0.000

Knows negative effect ofPacifiers on breastfeeding 55.3 40.4 0.000Using bottles on breastfeeding 63.4 44.0 0.000

Used bottle in response toRelatives 52.7 55.8 0.000Mass media 17.4 17.4 0.000Hospital advertisement 11.1 9.1 0.000

KAP, knowledge, attitudes, and practices.

EVALUATION OF COMMUNITY KAP TO BREASTFEEDING 175

practice of feeding babies by bottles comes from pressure bythe mother’s social network of family and friends (52.7% in LEand 55.8% in UE) and by media (17%) as shown in Table 3.

Discussion

Prenatal education is a powerful tool for increasing therates of any breastfeeding. Prenatal education can be highlyeffective in empowering vulnerable populations, especiallythe young and illiterate mothers. Printed materials givenalone during pregnancy were also found to increase women’sknowledge; however, a person-to-person approach might bemore effective.7,8 Effectiveness of prenatal education is in-creased when it is combined with postpartum follow-up.9 Wesuggest a multifaceted public health intervention by com-bining education by the health facility and the family-centeredapproach with educational messages from the mass media forencouraging positive breastfeeding attitudes in the family andwider community.

Our study indicates that early initiation of breastfeedingcontinues to be significantly delayed among all mothers butmore in LE than those of UE and that early initiation throughskin-to-skin contact is rarely implemented. These findingscould be explained by the higher prevalence of hospital de-liveries among mothers of LE compared with those in UE.Hospital routines may foster early separation of the motherand newborn, delaying breastfeeding. This is in contrast tohome deliveries, where early mother and baby contact iscommon. Hospital practices can affect breastfeeding evenmonths after discharge.10,11

Mothers’ overall knowledge about the benefits of skin-to-skin care is poor, especially in UE. This is probably due tothe effect of education, as the higher the education level ofthe mother the more likely she was to know more about thebenefits of both early initiation and skin-to-skin care forthe baby and mother. The difference was again statisticallysignificant for almost all of the benefits of skin-to-skin careexcept its effect on breastfeeding. In another study we re-ported that staff resisted skin-to-skin care and regarded asculturally inappropriate.12 A systematic review that evalu-ated evidence about promotion programs that are effective atincreasing the number of women who start to breastfeed andtheir impact on the duration and/or exclusivity of breast-feeding showed that BFHI implementation, training of healthprofessionals, social support from health professionals, peersupport, and media campaigns were most effective, but theyconcluded that mostly it was the multifaceted interventionsthat were most effective in improving such practices.13,14

Bedding-in was much more common than rooming-in be-cause of the limited number of infant cots in Egyptian hos-pitals. Separation was more common in private hospitals.Younger mothers preferred to keep their baby in a cot neartheir bed, whereas older mothers seemed to prefer to keeptheir baby in the same bed.13

The practice of scheduled feeding by mothers has signifi-cantly decreased compared with the preliminary BFHI sur-veys conducted in the early 1990s in Egypt. More motherswith higher education mentioned that they know the benefitsof responding to their babies’ cues.12,14

Pain in the nipple was more common among mothers inUE. In LE it was the commonest cause for supplementationfollowed by maternal illness. Nipple pain, as a cause for

supplementation, was significantly more commonly reportedby younger mothers with little or no education. Incorrect at-tachment at the breast is the commonest cause of nipple pain,particularly in first-time mothers. This fits the profile of theyoung, inexperienced, and undereducated mothers. It indi-cates the need for training primary healthcare staff and peercounsellors to counsel and monitor those mothers more clo-sely in the early postpartum period and first 6 weeks of life toensure successful continuation of exclusive breastfeeding.15,16

The practice of feeding babies by bottles is common andcould also possibly lead to incorrect latch on and nipple pain.Bottle use is pressured by the social network of family andfriends (50%) and less from the media (17%). However,mothers report they are influenced by hospital advertise-ments of bottles and infant milk formula (11.1% in LE and 9%in UE; p < 0.001).

It is clear that more mothers in LE are knowledgeable aboutthe hazards of bottles and pacifiers and that they prefer tosoothe and comfort their baby by carrying them (77.9%) ratherthan to give them nipples or teats, compared with 66.5% ofmothers in UE who practiced holding their babies as a meansfor soothing them.

The use of pacifiers and baby bottles is prevalent among theyounger mothers, who are probably also primiparous moth-ers. These mothers may receive more pressure from their so-cial network to offer their babies teats and nipples, with noknowledge about their negative effect on breastfeeding andwithout teaching regarding alternative ways to soothing theirbabies. It is clear that health staff and media campaigns needto focus on raising awareness of young, first-time mothers andtheir family members about the hazards of nipples and teats.Such campaigns will need to develop materials that wouldprovide mothers with ways of soothing babies other than useof pacifiers.17,18

It was observed that the practice of giving unaltered animalmilk to infants before 6 months of age has decreased signifi-cantly over the past decade.6 The rise in the use of infant milkformula reflects a change in attitudes of mothers toward thetype of supplements to give to babies. The change in practicefrom feeding animal milk to formula feeds as a supplementwith breastfeeding reflects either more affluence or access tosubsidized formula or unnecessary prescription by pediatricstaff influenced by the aggressive marketing tactics of infantmilk formula companies. Egypt has not fully enacted the In-ternational Code of Marketing of Breastmilk Substitutes as alaw, and many healthcare staff are not knowledgeable aboutthe Code. In another study we found that many of the staffreported that they accepted free supplies and gifts form infantmilk formula companies.14 This reinforces the need to trainstaff (Step 2 of the Ten Steps).13,14

The knowledge of mothers about the hazards of unneces-sary supplements was significantly higher in the mothers ofLE compared with those of UE. This widespread practice ofsupplementation without clinical need contributes to thecontinued morbidity rates in Egypt from diarrhea and otherdiseases despite the success achieved by the diarrheal controlprograms in the past.19–23

In other countries, strategies that used the risk approach toimprove exclusive breastfeeding rates in the first 6 monthshave been shown to be effective in decreasing the introductionof necessary supplements given to babies. The risk approachfocuses on highlighting the harms associated with a certain

176 ABUL-FADL ET AL.

practice. Learning from the success stories in these countriesmay be useful in design of social marketing campaigns basedon the risk approach.15–19

Only one-half of the mothers participating in this studyknew that exclusive breastfeeding entails feeding babies on noother solid foods or liquids other than breastmilk and with anemphasis on increasing the frequency of a breastfeed (on-demand feeding) and that this is the optimal way to increasemilk supply. Other previous KAP studies conducted in Egypthave shown that the most common cause for early cessation ofbreastfeeding was inadequate breastmilk supply.20 Methodsfor increasing milk supply include increasing the frequency offeeding, expressing breastmilk after a feed to ensure adequateemptying of milk, and cuddling and holding the baby as ameans of stimulating more brain oxytocin through skin-to-skin contact.24,25 Such practices were less readily used bymothers, especially by mothers of UE. The use of galactago-gues is not reported as a commonly used method for in-creasing milk supply except among the younger age group ofmothers. Teenage childbearing in Egypt represents 10% of themotherhood prevalence, and two-thirds of teen-aged mothers(8%) had their first child before 18 years of age.6

Mothers learned about how to increase their milk supplymainly from their social network of family or friends in LE.Rarely were healthcare workers mentioned as a source ofbreastfeeding information. In LE more mothers mentionedthat infant feeding information came from media (43%)compared with 20% in UE. The older the mother and thehigher her level of education, the more likely was she to beinfluenced by the media. Mothers who were younger and lesseducated were more likely to be influenced by informationreceived from their circle of family and friends.16 Media playsan important role in the mothers’ lives and represents animportant source of information that influences mothers’practices and child health. When used in a culturally effectivemanner it becomes a vitally important educational tool forreaching out to mothers of different needs and socioeconomiclevels in the society. The design and formulation of effective,well-studied media campaigns can shape the health andsurvival profiles of Egyptian children.26–30

Poverty remains a major problem in Egypt, as 19% of thepopulation are below the poverty line, and poverty ap-proaches 40–60% in some UE governorates. Poverty is asso-ciated with illiteracy and ignorance, which is prevalentamong older family members who can have adverse effects onbreastfeeding practices. Also, those mothers living in povertyalso suffer from depression, which can adversely influencebreastfeeding duration.31–33

Our study is unique in that it compares the regional dif-ferences between UE, which has higher mortality rates, withthose of LE, which has lower mortality rates.6 Becausebreastfeeding saves lives, an evaluation of the differences inunfriendly breastfeeding practices can identify some of thedeterminants associated with higher infant mortality rates.

Most important is that family members and social networkswere identified in this study as key influential groups. Otherin-depth studies have shown how the father, mother’s mo-ther, and mother-in-law have a great impact on the mother’sdecisions and practices in the perinatal period.34 In this studylower educational levels were consistently associated withpoor feeding practices. Given the higher illiteracy rates ofolder family members, particularly in UE, their influence

would explain the link between the prevailing poor practicesand persistently higher mortality rates in UE.6

This study was limited by the sampling method (conve-nience sample) and that the mothers were beyond the im-mediate postpartum period (up to 24 months). Prospectivestudies designed to elicit similar information for familymembers about their KAP towards breastfeeding support inEgypt would be an ideal next step.

Conclusions

Implementing the Ten Steps of the updated BFHI forachieving successful breastfeeding throughout the communitycould be a powerful educational tool when expanded to targetboth home and hospital-based deliveries. This requires in-volving the Maternal Child Health midwives and traditionalbirth attendants with the training of hospital staff. In addition,work is needed at the community level through peer counsel-ors and mother-to-mother support groups, taking into accountcultural differences. Targeting family members throughout theimplementation of BFHI educational activities and mediacampaigns is a need identified by this study for improving theoutcome of the BFHI on community practices. Training mediapersonnel on how to address the different needs of mothers invarious social classes and age groups and having differentlevels of education can be also effective in reaching masses.

Acknowledgments

We would like to express our gratitude to the UNICEF,Cairo Office that partly funded the Egyptian Lactation Con-sultant Association to do the survey as well as the officials ofMaternal and Child Health in the Ministry of Health of Egyptwho facilitated and participated in the field work of the sur-vey. We are particularly grateful to the primary healthcareofficials and coordinators of breastfeeding in the 12 gover-norates for facilitating and supervising the data collectionphase. We would like to thank the Centre of Social and Pre-ventive Medicine at Cairo University for facilitating the ad-ministration of the survey. We would like to thank theHealthy Children Project for funding the participation of theirfaculty in this research project.

Disclosure Statement

The Egyptian authors worked as a team, with most vo-lunteering their activity as Egyptian Lactation ConsultantAssociation members, and were responsible for the design,acquisition of the data, analysis of the data, and the writing ofthis article. The authors from Healthy Children Project in theUnited States provided technical assistance throughout thestudy and in the writing of this article. No competing financialinterests exist.

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Address correspondence to:Azza M.A.M. Abul-Fadl, M.Sc., M.P.H., M.D., IBCLC

Department of PediatricsBenha Faculty of Medicine

Benha UniversityKaluibiya, 11211, Egypt

E-mail: azfadl@yahoo.com

178 ABUL-FADL ET AL.