The effectiveness of nursing intervention on breastfeeding-related problems among nursing mothers in selected primary health clinics in Lagos, Nigeria

Breastfeeding is a vital component of realizing every child’s right to the highest attainable standard of health, while respecting every mother’s right to make an informed decision about how to feed her baby. Several factors related to the mother and the baby has a negative effect on the duration of exclusive breastfeeding. Most breastfeeding mothers have experienced variety of diffi culties because of some of the techniques used. The broad objective of this study is to determine the effectiveness of nursing intervention on breastfeeding-related problems among nursing mothers in selected primary health clinics in Lagos, Nigeria. Three research questions were raised and three hypotheses were generated in line with the objectives. One of the hypotheses raised in the study was that there is no signifi cant difference between the pre and post knowledge level of participant on proper positioning of mother and baby after four weeks of training. One group pretest-posttest of quasi-experimental was used for this study. The study was conducted among mothers of children less than fi ve years who attended the selected Primary Health Care Centers (PHCs) in Oshodi-Isolo LGA for outpatient clinics and immunization. The multistage sampling technique was used. Two hundred and fourteen participants agreed to participate but only 204 showed up for the training given a response rate of 95.3%. The study results showed that immediate nursing intervention towards lactation related problems are very signifi cant in maintaining exclusive breastfeeding. Recommendations were made based on the fi ndings that all pregnant women should be educated on management of breastfeeding related problems prenatally and establishment of breastfeeding support groups should be adopted. Research Article The effectiveness of nursing intervention on breastfeeding-related problems among nursing mothers in selected primary health clinics in Lagos, Nigeria Folami F*, Ademuyiwa Y and Olowe A Department of Nursing, College of Medicine, University of Lagos, Nigeria Received: 05 November, 2018 Accepted: 14 November, 2018 Published: 15 November, 2018 *Corresponding authors: Doctor. FF Folami, Department of Nursing, College of Medicine, University of Lagos, Nigeria, E-mail:

Based on the World Health Organization global data on infant and young child feeding in Nigeria, 22.3% of children were exclusively breastfed for less than 4 months, while 17.2% were exclusively breastfed for less than 6 months, in the year 2010 [8,9]. The technique used in breastfeeding, especially mother-infant positioning and attachment or suckling by the infant, has been shown to be important for the effective transfer of milk from the breast to the child as well as for preventing nipple damage. Ziol-Guest & Imdad, Yawar, & Bhutta [10], evaluated mother-infant pairs in a maternity ward and observed that only 2% of pairs achieved optimal latch performance and only 0.2% achieved optimal mother-infant positioning.
Most breastfeeding mothers have experienced variety of diffi culties because of some of the techniques used by the mothers. It was observed during the child welfare clinic that many of the nursing mothers failed to practice exclusive breastfeeding as a result of some of the breastfeeding related problems they encountered while breastfeeding [11].

Background of the Study
Breastfeeding is a vital component of realizing every child's right to the highest attainable standard of health, while respecting every mother's right to make an informed decision about how to feed her baby [1]. Breastfeeding has many advantages for both mothers and infants. Several factors related to the mother and the baby such as the technique used in breastfeeding, especially mother-infant positioning, latch, and suckling by the infant have been shown to be important for the effective transfer of milk from the breast to the child as well as for preventing nipple damage [2,3]. Breast milk contains nutrients at percentages exactly suited to the needs of the infant for growth and development [4]. The importance of appropriate infant feeding and the vital role played by breastfeeding in child survival, growth, and development cannot be overemphasized [5,6]. The World Health Organization (WHO) has recommended two years breastfeeding; fi rst six of month's exclusive breastfeeding; more than eight times breastfeeding per day in the fi rst three months of an infant's life [7]. Considering that breastfeeding technique seems to be important for maintaining successful breastfeeding; this study explored the effectiveness of nursing intervention on breastfeedingrelated problems among nursing mothers in selected primary health care centers in Oshodi-Isolo LGA, Lagos, Nigeria.
The nursing intervention provides formal breastfeeding education to nursing mothers on the importance of breastfeeding and its attended benefi ts. The antenatal period affords an opportunity for providing pregnant women and their partners and families with information about the benefi ts of breastfeeding at a time when many decisions about infant feeding are being contemplated. Systematic review of the available evidence suggests that breastfeeding education is effective in increasing both the rate of breastfeeding initiation and breastfeeding duration [11,12]. The broad objective of this study is to determine the effectiveness of nursing intervention on breastfeeding-related problems among nursing mothers in selected primary health clinics in Lagos, Nigeria.

Conceptual Model
The theoretical model used to guide this study is the general systems theory. This theory was introduced by Ludwig Von Bertalanffy (1969) as a universal theory that could be applied to many fi elds of study. This theory explains the breaking of whole things into parts and the working of those parts in systems. The theory explains the relationship between wholes and parts, a description of concepts about them, and predictions about how the parts will behave and react [13]. This theory explains how effective breastfeeding is a function of the proper positioning, latch, proper emptying of the breast, and attachment of child to the mother's breast.

Proper Positioning of Mother and Baby
Studies conducted in North India reveal that there was good attachment in 42% mother-infant pairs and 60% mothers [13,14], held infants in correct position. A study in Bangladesh reported that correct breastfeeding position (74%) and good attachment (72.3%) as assessed by Health Care Workers [14].
Positioning of the baby's body is important for good attachment and successful breastfeeding. Most diffi culties can be avoided altogether if good attachment and positioning are achieved at the fi rst and early feeds [13]. The baby's positioning and attachment to the breast during breastfeeding are fundamental toward the occurrence of different sorts of nipple trauma.
Many studies indicate a statistically signifi cant association between position and holding variables for causing nipple lesions [12,15].

Maternal Breast Engorgement
Maternal breast engorgement is one of the most common problems in the postpartum period [16]. Maternal breast engorgement is one of the common breast implication occur in third and fourth postpartum day due to excessive production of milk, obstruction to outfl ow of milk or poor removal of milk by the baby. Engorgement symptoms occur most commonly between days 3 and 5, in that 2-3 of them experience tenderness on day 5, however some cases late as day 9-10. Breast engorgement is a major issue in the early postpartum period as the breast, under the infl uence of hormonal shift, increase milk production rapidly. For most women engorgement is at its height from 3 to 5 days after birth and slowly recedes but may last for 2 weeks [2].

Sore nipple
Improper suction is also described as a source of trauma which if corrected can become a protective factor [2]. The most frequent causes of sore nipples are incorrect positioning at the breast and suction trauma. During the fi rst two to four days after birth, the mother's nipples may feel tender at the beginning of a feeding as the baby's early suckling stretches her nipple and areolar tissue far back into his mouth. If a baby is well positioned at the breast, this temporary tenderness usually diminishes once the milk lets down, and disappears completely within a day or two [2]. A poorly latched baby may pinch off the nipple to protect his airway from a forceful milk-ejection refl ex. Sometimes a baby will pinch the nipple or irritate it due to a short frenulum, short tongue, small mouth, receding chin, a high palate, or other anatomical condition.
Nipple soreness that increases or lasts beyond the fi rst week should be interpreted as a warning that something is wrong.

Ineffective latch
The most important part of successful breastfeeding is in which the baby is held is crucial. When a good position and latch is obtained, breastfeeding can be a wonderful experience between mother and baby [3]. Nipple damage and mastitis were more common among mothers with poor positioning and latch [17]. Furthermore, breastfeeding problems were 2.44 times more common among mothers who practice ineffective latch compared to who had effective latch practice [6]. The most important factor in decreasing the incidence of nipple pain is the provision of education in relation to proper breastfeeding technique and latch on as well as anticipatory guidance regarding the high incidence of early postpartum nipple pain.

Research design
One group pretest-posttest of quasi-experimental was used for this study. This design involved comparing participants' included the use of research assistant to collect data but the two research assistants used for this study were well trained.

Results
A total of 214 participants agreed to participate but only 204 showed up for the training. Two hundred and four questionnaires were administered, returned, and also found adequate for analysis given a response rate of 95.3%. Table 1 shows that majority of the respondents 111 (54.4%) were within the age group 30-39, 191(93.6%) were married and about 46.1% were educated up to secondary school level. Majority were self-employed 156(76.4%), (3.9%) were housewives and 134(65.7%) earned N5000 -N20, 000 monthly. Table 2 presents the distribution of mothers according to the gravida, place of delivery, and whether they attended any breastfeeding education class.

Recommendations
Based on the fi ndings of this study, the following recommendations were made: All pregnant women should be informed about the benefi ts and management of breastfeeding problems prenatally.
All pregnant women should be helped to initiate breastfeeding within one hour of birth.
Foster the establishment of breastfeeding support groups and refer mothers to Lactation Consultants Mass media should intensify efforts by including more programs on breast feeding problems and solutions.