European Journal of Clinical Nutrition
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May 2002, Volume 56, Number 5, Pages 438-441
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Original Communication
Knowledge, attitude and practice of health workers in Keffi local government hospitals regarding Baby-Friendly Hospital Initiative (BFHI) practices
S N Okolo1 and C Ogbonna2

1Department of Paediatrics, Jos University Teaching Hospital, Jos, Nigeria

2Department of Community Health, Jos University Teaching Hospital, Jos, Nigeria

Correspondence to: S N Okolo, PO BOX 10349, Jos, Plateau State, Nigeria. E-mail:

Guarantor: SN Okolo.

Contributors: SN Okolo, C Ogbonna.


Objective: To assess the knowledge, attitude and practice of health workers towards Baby Friendly Hospital Initiative (BFHI) practices and thereafter plan an advocacy on BFHI training of the workers.

Design: A randomised cross-sectional study.

Seting: Ten out of 16 health facilities reflecting all the levels of healthcare provision in Keffi Local Government Area in Nassarawa State, Nigeria, were selected. Staff of these health facilities had not received BFHI training, although breastfeeding is the norm in this population, exclusive breastfeeding is almost zero.

Subjects: A total of 250 health workers (six doctors, 160 nurses and 84 auxiliary staff) met in the health facilities at the time of interview.

Intervention: A structured questionnaire based on 10 steps to successful breastfeeding was administered by one of the authors and a Lactad nurse between July and October 1995.

Results: Fifty-two (20.8%) were aware of the need for initiating breastfeeding within 30 min of birth and 92 (36.8%) were aware of breastfeeding support groups. However, there were significant differences in the level of awareness among the doctors compared to the other categories of health staff (P<0.05). Also, 48 (19.2%) of the health workers believed that babies less than 6 months of age should not be given water (statistical difference (P<0.05) between doctors' attitude and that of the other health workers). Thirteen (5.22%) health workers could demonstrate correct positioning and attachment.

Conclusion: There was general lack of awareness of some major recommended practices in the hospitals that will promote and sustain breastfeeding. There is therefore the need for policy changes and BFHI training for the staff of these health facilities to respond to the concern and growing need for proper infant/young child feeding.

European Journal of Clinical Nutrition (2002) 56, 326-337. DOI:10.1038/sj/ejcn/1601331


healthworkers; BFHI practices; knowledge


Breastfeeding is the first step in life which ensures that infants and young children get a healthy and nutritious start in life. It is one of the few consistent sources of energy-dense food, even into the second year of life. There is a wealth of information on the benefits of breastfeeding, especially exclusive breastfeeding (EBF), for the mother and infant (Savage King, 1994). Some of these are adequate growth, anti-infective properties and increased intelligence quotient. The danger and hazards of early supplementation and weaning have also been studied (Savage King, 1994, Cohen et al, 1994, Guldan et al, 1994, Castillo et al, 1996). These include growth faltering and increased susceptibility to infections. Breastfeeding is widely practiced in Nigeria but EBF rates in various studies have been extremely low (0% (Okolo et al, 1999) and 2% (Federal Office of Statistics, 1990)). Some of the major factors identified which influence EBF in some communities in the country included attitudes of health workers and policies of health facilities on breastfeeding (Ekele & Ahmed, 1997; Federal Ministry of Health, 1990; Malami, 1995; Ogbonna et al, 2000).

The initiation and establishment of breastfeeding following birth are crucial to increasing breastfeeding. Past efforts indicate that improved healthcare practices stand out as being the most promising means of reinforcing the pre-valence and duration of breastfeeding (Popkin et al, 1991).

The first response to the lack of support by health professionals for breastfeeding came from mothers themselves in America and Europe and was also noted in other studies (Borbala, 1994; Robertson, 1994). At present, most health workers are in a situation where they are expected to be knowledgeable without much training in new knowledge and skills. Textbooks on physiology and lactation do not contain practical guidance for the nurse or physician in the management of lactation, the correct position for breastfeeding or how breastfeeding can be initiated and continued following a ceasarean section. Early contact between child and mother, early introduction of breastfeeding, demand feeding and hospital rooming-in are practices in the hospital which will help to enhance initiation and sustainance of breastfeeding.

It is therefore necessary to determine the level of awareness among health workers in the healthcare system. It is also necessary is to assess the attitude and practices of such health workers towards breastfeeding. This would help proper mobilisation and training of the healthcare delivery system to respond to the concerns and growing need for proper infant/young child feeding practices. Studies in this region have shown that 53.2% of pregnant mothers deliver in health facilities while 46.8% deliver outside the health facilities. This mobilisation will empower the health workers at every level with the knowledge and confidence on how to support mothers to successfully breastfeed their infants. Also, the Baby Friendly Hospital Initiative (BFHI) programme encourages BFHI-trained health workers to establish community-based breastfeeding support groups and Baby Friendly Households (BFHH) to meet the needs of those mothers who deliver at home.

Subjects and method

The study was carried out between July and October 1995 in the Keffi Local Government Area (LGA). The LGA has two districts with nine primary health care (PHC) facilities, one comprehensive health centre (CHC), five private hospitals and one general hospital. These facilities have not received any BFHI training.

Ten health facilities were selected to reflect all the levels of healthcare provision in the districts. These included the only existing general hospital and CHC in the local government area, five PHCs and three private hospitals selected from the nine PHCs and five private hospitals in the LGA. One of the authors and a lactad nurse (trained in lactation management) visited the sampled health facilities during the study period and administered the questionnaire. A structured interviewer questionnaire based on BFHI practices summarised as 10 steps to successful breastfeeding was pre-tested and administered to 250 health workers at these health facilities. All health care service providers at the health facilities at the time of the study were interviewed except two nurses who did not consent to the study and were excluded. The health workers interviewed included six medical doctors (with 4-7 y work experience), 160 nurses and 84 auxiliary workers. Out of the 250 health workers studied, 170 were female.

Data analysis

The data were entered and analysed on EPI-INFO Version 5 software by one of the authors, who is a statistician. The chi2 test was used to test for differences on the awareness, attitude and practice of the various groups. Yates' correction factor for continuity was applied for small numbers. The level of significance between proportions was set at P<0.05.


shows the level of awareness of BFHI practices among the various categories of health workers. Awareness of starting/initiating breastfeeding within 30 min of delivery was lowest for all health workers, as less than 50% of each category interviewed had this knowledge. None of the auxillary health workers was aware of the existence and duties of lactation support groups. The differences in the level of awareness of these two practices between the doctors and the other categories of health workers were statistically significant (P<0.05).

shows a fairly correct attitude towards BFHI practices, except for the belief that complementary feeding should start at 6 months, where less than 50% of each category of health workers studied had an incorrect attitude. Here also the auxiliary workers ranked lowest (9.5%).

shows that less than 20% of each category could properly demonstrate correct positioning and correct attachment of babies to the breast. The auxiliary workers ranked lowest, followed by the nurses.

However, it is interesting to note that the information (personal hygiene, washing of the breasts before breastfeeding, pulling out of the nipple and maternal nutrition) that these health workers gave mothers at the antenatal clinics did not cover the benefits and management of breastfeeding.


Among the most important challenges that we face in mobilising the scientific and social forces and resources to meet the health and development needs of women and children as we enter the twenty-first century is that of ensuring that infants and young children get a healthy nutritive start in life. The first step for that start in life is breastfeeding.

The first opportunities for promoting breastfeeding should occur in the health services, the ante-natal clinics, the delivery room and just after birth. The health worker should be responsible for this and should ensure practices and training that promote, protect and support breastfeeding.

However, our study demonstrated lack of awareness of some of the major recommended practices in the hospital that will promote and sustain breastfeeding. For instance, the information (personal hygiene, washing of the breasts before breastfeeding, pulling out the nipple and maternal nutrition) these health workers gave to the mothers at the antenatal clinics did not cover the benefits and management of breastfeeding. Also, only 19.2% of the health workers interviewed believed that babies less than 6 months of age should not be given water. Giving anything other than breast milk interferes with the baby's demand suckling and also increases the prevalence of both diarrhoea and respiratory infection (Victoria et al, 1989; Popkin et al, 1990). At the same time it has been shown that fully breastfed babies do not need water supplements even in a hot dry climate (Sachdev et al, 1991). Also, only 5.2% of the health workers interviewed were able to demonstrate correct positioning of the baby for breastfeeding. Similarly, a low proportion (5.2%) of health workers could correctly attach the baby to the breast. Woolridge and colleagues, using ultrasound to show how babies remove milk from the breast, concluded that correct positioning and attachment of the baby at the breast is essential for the efficient transfer of milk and may be the single most important measure to prevent and treat the majority of lactation problems (Woolridge, 1986). Health professionals need to be able to help a mother to do it right, especially when she is inexperienced or lacks experienced support at home. Only 20.8% of the health workers were aware of the need to initiate breastfeeding within 30 min of birth. In addition, a low proportion (36.8%) was aware of the existence and duties of breastfeeding support groups. These two practices in the hospital have been shown to enhance initiation and maintenance of breastfeeding (World Health Organization/UNICEF, 1989). A delay in the onset of breastfeeding may lead to hypoglycaemia, hypothermia and acidosis, especially among high-risk low birth weight infants (Anderson et al, 1993; Van den Bosch & Bullough, 1990; Costellor, 1993).

The findings in this study have highlighted those in earlier studies (Borbala, 1994; Robertson, 1994) in Hungary and former-Yugoslavia that noted the lack of awareness of breastfeeding practices among health professionals as a major obstacle to proper breastfeeding practices.

We therefore see the need for health professionals to play an active role by ensuring not only that families are well informed, but also that mothers receive appropriate help. There is the need for properly trained and professionally supported specialists who can lead and educate students and practitioners in the subject, and set standards of practice in healthcare institutions (Hayles, 1990). The health worker should therefore use the knowledge and skills gained in such training to promote, support and protect breastfeeding both at the health facilities and in the communities in collaboration with traditional birth attendants (TBA), since a reasonable proportion of pregnant mothers still deliver at home.


We are grateful to the staff of the 10 health facilities for their cooperation and also to Mr Sylvanus T Chime for the secretarial assistance.


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Table 1 Health workers' awareness of BFHI practices

Table 2 Health workers' attitude towards BFHI practices

Table 3 Health workers' practice on BFHI practices

Received 25 April 2001; revised 3 September 2001; accepted 9 September 2001
May 2002, Volume 56, Number 5, Pages 438-441
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