Knowledge, attitude, and breast-feeding practices of postnatal mothers in Jammu: A community hospital based cross sectional study.

CONTEXT: In spite of convincing evidence of the benefits of breastfeeding, breast feeding rates are less than satisfactory, thus pinpointing large gaps, which need to be identified and addressed. AIMS: To examine the knowledge, attitude and practices of postnatal mothers towards breast feeding. SETTINGS AND
DESIGN: Community Hospital-based CrossSectional study. METHODS AND MATERIALS: The study was done for a period of 4 months among 178 women attending outpatient department of paediatrics. Data collection was done with the help of face to face interview using pre-tested pre-designed structured questionnaire having information about demographic profile of study participants and knowledge, attitude and practices of breast feeding. STATISTICAL ANALYSIS USED: The data was presented as frequencies and percentages.
RESULTS: Majority (89.9%) of the mothers were breast feeding, however, only 42.7% of the mothers exclusively breast fed their kids. 82.5% of the mothers believe that cow's milk can be substituted for breast milk. All the mothers continue to breast fed their babies during sickness. Almost all respondents were aware of the importance of colostrum, while 80.3% had the misconception that they should stop breast feeding once when weaning was started.
CONCLUSIONS: Mothers should be counselled during antenatal period and all the misconceptions regarding breast feeding should be appropriately addressed. Copyright:

Introduction

Breastfeeding has been branded as an effective tool to achieve the Global Strategy for Women's, Children's and Adolescents’ Health (2016-2030), which was launched alongside the Sustainable Development Goals as a roadmap for ending preventable deaths in a generation.[1] Since ancient times breast feeding is considered a basic human activity essential for infant survival. Circumstantial evidence is already established for advantages gained by breast fed babies over non breast-fed babies with respect to nutrition, cognitive abilities, intelligence and overall health not only in initial years of life but also in adulthood where it decreases the likelihood of diabetes, obesity, hypertension, cancers and many other diseases. Exclusively breast feeding (EBF) for 6 months of life after birth is universal recommendation by the WHO.[2] It means only breast milk should be given, no other liquids or solids including water are to be given. However, EBF allows the use of oral rehydration solution (ORS), drops or syrups of vitamins, minerals and medicines. After 6 months breast milk is not able to fulfil their needs, therefore, infants should start receiving nutritionally adequate and safe complementary foods while continuing with breastfeeding for up to 2 years or more.

Breast feeding is a blessing both for mothers and babies, as a recent lancet breastfeeding series estimates that optimal breastfeeding could help prevent 20,000 maternal deaths from breast cancer every year.[3] Exclusive breastfeeding for the first 6 months is also a natural contraceptive that can aid in increasing birth spacing.[4]

In 2012, a World Health Assembly resolution endorsed a comprehensive implementation plan on maternal, infant and young child nutrition, which specified 6 global nutrition targets for 2025.[5] The 5thtarget focused on increasing the rate of exclusive breastfeeding in the first 6 months up to at least 50% from baseline (2008-2012) breast feeding rates, 38 percent by 2025.[6] Globally, only 37 percent of infants younger than 6months are exclusively breastfed in low- and middle-income countries.[7] Furthermore, Global estimates reveal that only 42 percent of just born are breastfed within an hourof birth[8] and only 46 percent continue to breastfeed until the age of 2.[9] Global evidence shows that children who are exclusively breastfed are 14 times more likely to survive the first 6months of life than non-breastfed children.[10]

Even after strong recommendations in favour of exclusive breast feeding still in our set up the practice of EBF seems to be not very promising. According to the National Family Health Survey-Round 4 (NFHS-4), only 54.9 percent of children aged 0-6 months are exclusively breastfed.[11] Traditional feeding practices, introduction of pre-lacteal feeds like water, honey, jaggery or sugar water and food supplementation prior to 6 months hampers EBF.

The knowledge and attitudes towards exclusive breastfeeding is influenced by the number of factors like family pressures, literacy level of mother, socio-cultural traditions, maternal age, marital status, family income, social class, family size, place of delivery, and time of initiation of first breastfeeding. Most of the children who are not exclusively breastfed consume water, milk, formula, or complementary food in addition to breast milk, often leading to infections in unsafe environments.

There is very less data available on the determinants of exclusive breastfeeding among lactating mothers. So, there is an imperative need to explore these factors. This will further help to reduce infant morbidity and mortality. With this background the present study was conceived to examine the knowledge, attitudes and practices of postnatal mothers towards breast feeding.

Methodology

A cross-sectional study was conducted for a period of 4months from Jan 2019 to April 2019 at a community hospital in North India. All postnatal mothers who were attending immunization clinic and the paediatric outpatient department for the treatment of minor illnesses were included in study using non probability convenience sampling.

Inclusion criteria

Mothers of healthy neonates and infants aged 1 month and above (up to 2 years) who were being breast fed and children born between 37 and 42 weeks of gestation.

Exclusion criteria

Mothers of preterm babies, multiple gestations, those mothers who did not give their consent for the study and babies having congenital anomalies and congenital malformations were excluded.

The study was initiated after taking approval by the institutional ethics committee. The purpose of study was explained to mothers and verbal consent was obtained from those women who agreed to participate in the study. The total participants enrolled were 178. A face to face interview of study participants was done for collection of data in a separate room. A pre-designed and pre-tested structured questionnaire was used. It consisted of two parts; first part was having questions eliciting information about the demographic profile of participants: Age, religion, type of family, working status of mothers, educational level, monthly income of family, place of delivery and sex of child. The second part contains questions assessing knowledge, attitudes and practices towards breastfeeding among postnatal mothers. The questions were asked in a local language and the time taken to complete the questionnaire was approximately between 15–20 minutes. After the completion of interview, all the mothers were informed about the significance of prolonged breast feeding up to period of 2 years and beyond. Confidentiality of participants was assured and maintained. Data was entered in Microsoft Excel and using descriptive statistics data was expressed in frequencies and percentages.

Results

178 postpartum mothers were studied of whom approximately 1/2 of women (48.3%) belonged to 26–30 years age group, majority (70.9%) of them were Hindus and mostly residing in rural areas (62.9%). Majority (95.5%) of them had institutional delivery. 52.2% of the mothers had delivered male child. Nearly half of the participants were educated up to higher secondary school (46.6%) and 38.7% were graduate and above [Table 1].

Table 1

Socio-Demographic Characteristics of Study Participants

Characteristics		Number	Percentage
Mothers age (yrs)	<20	03	1.6
	21-25	51	28.7
	26-30	86	48.3
	31-35	34	19.1
	>35	04	2.2
Religion	Hindu	126	70.9
	Muslims	50	28.0
	Sikhs	02	1.1
Caste	General	70	39.5
	SC	20	11.7
	ST	46	25.8
	Others	41	23.0
Monthly Income (in Rs)	<3000	36	20.2
	3000-5000	39	21.9
	5000-7000	31	17.4
	>7000	72	40.5
Educational Status	Illiterate	10	5.8
	Primary	16	8.9
	Secondary and Higher Secondary	83	46.6
	Graduate and above	69	38.7
Employment	Yes	52	29.2
	No	126	70.8
Type of family	Nuclear	75	42.1
	Joint	103	57.9
Residence	Rural	112	62.9
	Urban	66	37.1
Place of delivery	Hospital	170	95.5
	Home	08	4.5
Sex of child	Male	93	52.2
	Female	85	47.8

All the females were aware of the fact that colostrum is first breast milk and plays a vital role in building the immunity of the newborn. Nearly all the mothers agreed that for the first 6 months the child should be given only breast milk and nothing else. 85.9% of the mothers believe that they can continue to breast feed their kids up to 2 years. Approximately 3/4 th of women stated that the breasts should be cleaned with warm water before feeding. Majority of the mothers agreed that breast feeding gives protection against the diseases of the breast. [Table 2]

Table 2

Distribution of Study Participants according to Knowledge Regarding Breastfeeding

Characteristics	Number	Percentage
First breast milk is called colostrums	168	94.4
Colostrum helps in maintaining immunity of the baby	177	99.4
The baby should be burped after each feed	159	89.3
Breast feeding can be continued up to 2 years	153	85.9
For first 6 months, breast milk should be given exclusively	170	95.5
Lactating mother should include healthy food in her diet to increase secretion of milk	168	94.4
The mother should sit comfortably at the time of breast feeding	164	92.1
While breastfeeding, an eye to eye contact with the baby should be maintained	139	78
The breast should be cleaned with warm water before breast feeding	131	73.5
Baby should not be sleeping while breastfeeding	162	91.0`
Breast feeding infants shows better bonding with their mother.	175	98.3
Mothers who do not breast feed their babies can suffer from diseases affecting breast	172	96.6
Mother should restrain from feeding the child if she has fever	54	30.3
Breastfeeding should be stopped with the start of weaning	143	80.3

Only 1/4 th of the participants agreed that formula feeding was more convenient than breast feeding, whereas 2/3 believed that breast fed babies were healthier than bottle fed babies. Most of the mothers felt that exclusive breast feeding has advantages, only 1/2 of the females felt that breast feeding can be done in public places [Table 3].

Table 3

Attitude of Study Participants towards Breast Feeding

Characteristics	Number	Percentage
Breast fed babies are healthier than bottle fed babies	108	60.6
Formula feeding is more convenient as compared to breast feeding	48	26.9
Breast milk is easily digestible than formula milk	147	82.5
Exclusive Breast Feeding infant for 6 months has advantages	167	93.8
Cow’s milk can be substituted for breast milk	98	55.0
Women should breast feed in public places	98	55.0

Even though majority of the women agreed that exclusive breast feeding is essential for babies, only 42. 7% had practiced EBF. Also, only 1/2 of the females initiated feeding in the 1 hour of birth. Two thirds of the women had given pre-lacteal feed to their babies, mostly holy water (44.3%) followed by honey. Nearly 1/2 of the mothers were feeding babies 4-8 times a day including night feeding. All the mothers were of the view that breast feeding should be continued in sickness [Table 4].

Table 4

Breast Feeding Practices among Lactating Mothers

Breast Feeding Practices	Number	Percentage
Time of Initiation of Breast Feeding (in hrs)
≤1	92	51.6
2-5	33	18.5
6-24	25	14.4
>24	10	5.4
Not breast fed	18	10.1
Discarded Colostrum
Yes	70	39.3
No	108	60.7
Pre Lacteal Feeds given
Yes	116	65.1
No	62	34.9
Types of pre lacteal feeds given
Water	15	8.4
Honey	60	33.7
Holy water	79	44.3
*Others	24	13.4
Types of breast feeding
EBF	76	42.6
Mixed Feeding	84	47.2
Exclusive top feeding	18	10.2
Number of feeds given to babies per day
<4 times	45	25.3
4-8 times	57	32.0
8-12 times	76	42.7
Do you feed your babies during night
Yes	159	89.3
No	19	10.7
Do you Breast feed your child when you are sick
Yes	178	100
No	00	00

*Jaggery, Ghutti, Cow’s milk

Discussion

Breast feeding is a fundamental factor influencing long term health of new born babies and infants. The government of India launched National Health Mission in 2013, one of the programmatic components of which is the Reproductive-Maternal- Neonatal-Child and Adolescent Health (RMNCH + A) which envisages the promotion of health and wellness of new born and children through the existing health care delivery system.

In the present study, only (4.5%) mothers were having inadequate knowledge regarding the duration of exclusive breast feeding to their infants, whereas in a study conducted by Girish S et al. 38% mothers were not aware of duration of EBF.[12] Our study found that 42.7% infants were exclusive breast fed, whereas in a study conducted by DJ Bhanderi et al. in rural population, the EBF rate was 49.7%.[13] Almost all the mothers 98.3% believed that breast feeding boosts mother and child bonding. This is large number as compared to the findings of studies conducted by Priya Sultania et al. (71%)[14] and Eman S Mohd et al. (78.6%).[15] Colostrum was given to 60.7% babies which is less than that reported by studies done in Madhya Pradesh (82%) and Varanasi (90%).[1617]

Indian National guidelines on Infant and Young child feeding recommend that the initiation of breastfeeding should begin immediately after birth, preferably within 1 hour.[18] In our study this recommendation was followed only by 1/2 of the mothers. This finding is corroborated by various studies done in different parts of India though the rates were higher for initiation of breast feeding within 1 hour (68.7%) and (74.2%) within 6hours.[1920] Even though mothers were fully aware of the importance of colostrum 39.3% mothers have discarded it in our study, whereas Singh J,et al.[21] in their study reported that 71.4% mothers did not provide first milk to their babies.

Studies from various parts of India have reported different rates of pre lacteal feeds viz 4.3%, 27%, 32.03%, 50.81%.[14222324] In our study, the rate of pre lacteal feeds was 65.1%. Family customs and pressure from relatives might be the possible reasons for giving pre lacteal feeds. Holy water was the most commonly used pre lacteal feed followed by honey, whereas in the studies conducted by other authors honey was the most common pre lacteal feed.[2425]

89.3% of the women fed their infants during night, this finding is similar to the study conducted by Chaudhary et al. in Nepal.[26]

Conclusion and Recommendations

It is evident from the present study that the participants have good knowledge and attitude regarding feeding, however the breast feeding practices are not in tune with their satisfactorily knowledge which points towards the gap in the education and counselling of women regarding breast feeding. This study reiterates the need for strengthening public health information, education and communication campaigns to promote breast-feeding. This preliminary and baseline information can be shared with the all the relevant stakeholders and health professionals especially those who are working at primary level and so that they can devise targeted breastfeeding interventions on issues pertinent at each stage of pregnancy and lactation.

Limitation of the Study

The findings of the present study may not be generalizable due to its cross-sectional nature and small sample size, however, in depth interviews and focus group discussions (FGDs) may be planned to focus on the qualitative aspects of breast feeding. These studies may be instrumental in delving into the deep rooted beliefs at individual, family and community level, which if addressed appropriately may help promote the culture of breast feeding among Indian mothers.

Relevance of the study

It is hoped that this review will serve as baseline information for any upcoming longitudinal studies on breastfeeding in North India.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.