Assessment of the Knowledge and Perception Regarding Breast-feeding and Immunization Among the Post-natal mothers at a Tertiary Care Hospital, Bangalore - A Cross-sectional Study

Introduction

Breastfeeding is a cornerstone of infant and young child survival, delivering health, nutritional, and emotional benefits to both children and mothers. It is also part of a sustainable food system.¹ Exclusive breastfeeding is crucial and essential for optimal growth and development, providing a powerful defence against all forms of childhood malnutrition and many communicable diseases, while also strengthening the mother-child bond.² Globally, only 38% of infants aged 0-6 months are exclusively breastfed. According to recent analyses, suboptimal breastfeeding practices, including non-exclusive breastfeeding constitute 11% of mortality in children under five years of age.^3,4,6 Vaccines are among the greatest advances in global health and development, being one of the most cost-effective means of advancing global welfare. Breastfeeding, along with immunization, is pivotal for ensuring the health and well-being of infants and post-natal mothers, significantly reducing infant and neonatal mortality.⁵

In India, the burden of infant mortality and morbidity remains substantial with preventable diseases such as pneumonia, diarrhoea, and vaccine-preventable illnesses contributing significantly to the mortality rate.⁶ According to the World Health Organization, India continues to face challenges in achieving optimal breastfeeding rates, with only 55% of infants being exclusively breastfed in the first six months of life.⁷ In India, strategies such as the Reproductive, Maternal, Newborn, Child and Adolescent Health program, Baby-Friendly Hospital Initiative and National Health Programs like the Mothers’ Absolute Affection program, Pradhan Mantri Surakshit Matritva Abhiyan, and Intensified Mission Indradhanush aim to improve breastfeeding practices and immunization coverage.^8-10

Despite improvements in immunization coverage, disparities persist across different regions and socioeconomic groups, leading to unequal access to life-saving vaccines.¹¹ Integrated Management of Neo-natal and Childhood Illness recommends systematic assessment of breastfeeding and emphasized postnatal counselling of the mother on proper positioning and attachment of the infant to the breast.¹² Despite efforts to address these challenges, there remains a gap in understanding the knowledge and perception of postnatal mothers towards breastfeeding, immuni-zation, and healthcare facilities. This gap limits the development of targeted interventions and hampers efforts to improve maternal and child health outcomes.

It is essential to have evidence-based interventions and policies aimed at improving maternal and child health outcomes in India. Therefore, there is a compelling need for comprehensive studies that assess the knowledge and perception of postnatal mothers to identify barriers and facilitators to optimal breastfeeding, immunization, and healthcare facility utilization.

Materials and Methods

A descriptive cross-sectional study was conducted to assess the knowledge and practice regarding breast feeding and immunization and factors influencing it among post-natal mothers admitted in-born wards, kangaroo mother care wards, and post-partum care wards of Vani Vilas Hospital, Bengaluru. The present study was conducted over a period of six months from March 2023 to August 2023.

Sample size

According to the study done by Pranita Achyut et al., the expected proportion of participants with knowledge regarding the time of initiation of breast feeding is 73.75%.⁴ Sample size was calculated using the formula, N=Z2 p (1-p)/ d2, with the standard table value for a 95% confidence interval (1.96) and the absolute precision of 8%. After adding 10% attrition to the initial sample size of 131.47, the final sample size was rounded to 131.

Methodology of data collection

After obtaining clearance from the Institutional Ethics Committee and approval from the medical superintendent of the Vanivilas hospital, participants were informed regarding the study. Those who met the inclusion criteria were enrolled after obtaining the written informed consent. Using the simple random sampling method, the participants were randomly chosen using a random number generator. Data were collected using a pre-tested, semi-structured, questionnaire sourced from the Centers for Disease Control and Prevention (CDC) breast feeding module. The questionnaire comprised details regarding socio-demographic characteristics, mode of delivery, mother and baby details, knowledge and perceptions about breastfeeding & immunization and their actual practices. The responses of the participants were gathered through a face-to-face interview method.

Inclusion criteria

1. Patient willing to give informed consent for the study.

2. Mothers aged above 18 years.

3. Delivered between 37 and 42 gestation weeks, within post-partum period of six weeks.

4. No major birth defects such as congenital heart disease, cleft lip/cleft palate and Downs syndrome in the baby.

Exclusion criteria

1. Mothers with active chronic diseases like tuberculosis, etc. or any other medical conditions.

2. Mothers on medications for which breastfeeding is contraindicated.

3. Multiple gestations.

4. Babies with galactosemia, lactose intolerance.

Statistical analysis

The data collected were entered in Microsoft Excel and analysed using SPSS version 26.0. Sociodemographic data were presented using descriptive statistics. Non-parametric test was used to determine the significant association between the categorical variables. Data are presented in the form of tables and figures.

The Table 2 data reveals that 49.6% respondents received prenatal breastfeeding guidance and 90.1% recognize the benefits of colostrum. Most believed exclusive breastfeeding should continue for six months (73.3%) and 64.9% opined that breastfeeding alone is sufficient during this period. Awareness about breastfeeding benefits and milk banks was high (68.7% and 50.4% respectively). Nearly all infants received initial vaccinations (93.9%) and 59.5% agreed that immunization reduces disease risk. Additionally, 93.9% of mothers received two TT vaccines during pregnancy, with 64.1% being aware that these protect both the mother and the baby, and 74.0% knew about the National Immunization Schedule.

Figure 1 illustrates the awareness levels of postnatal mothers regarding signs of adequate infant feeding. It shows that 57.6% of mothers recognized regular urination and stooling as indicators, 23.5% identified burping after a back rub, 87.7% considered adequate sleep for a few hours after feeding and 2.62% associated progressive weight gain with sufficient feeding. Overall, the participants' knowledge about breastfeeding and immunization indicates that 57.2% had good knowledge about feeding practices, 45.8% were well-informed about exclusive breastfeeding and 44.3% had a fair knowledge of immunization.

The survey reflected a positive attitude among post-natal mothers towards infant care: 92.4% intended to exclusively breastfeed and 93.1% preferred manually expressed milk over the milk from milk bank, if needed. Despite this, only 2.3% received TT vaccination during pregnancy. A strong majority (93.9%) were committed to fully immunizing their child and 97.7% planned to adhere to the vaccination schedule (Table 3).

The Figure 2 illustrates that 44.3% of participants believed they would not have enough milk, 32.1% reported that a health professional advised them against breastfeeding for medical reasons and 19.8% were unable to breastfeed as they were ill and were on medications.

The Table 4 summarizes breastfeeding practices among participants. Most mothers (90.8%) did not give pre-lacteal feeds and 94.7% were advised to exclusively breastfeed. A majority (82.4%) received guidance on breastfeeding techniques. Common initiation times were within 2-3 hours post-delivery (42.8%). Challenges included sucking and latching difficulties (12.2%), but 83.2% reported no issues. Colostrum was given by 87%, and 96.9% practiced exclusive breastfeeding during the first two weeks. Night feeding was frequent, with 59.5% feeding every two hours and 90.1% ensuring adequate night-time feeding.

The Table 4 summarizes breastfeeding practices among participants. Most mothers (90.8%) did not give pre-lacteal feeds, and 94.7% were advised to exclusively breastfeed. A majority (82.4%) received guidance on breastfeeding techniques. Common initiation times were within 2-3 hours post-delivery (42.8%). Challenges included sucking and latching difficulties (12.2%), but 83.2% reported no issues. Colostrum was given by 87%, and 96.9% practiced exclusive breastfeeding during the first two weeks. Night feeding was frequent, with 59.5% feeding every two hours and 90.1% ensuring adequate night-time feeding.

The participants' responses on feeding practices and positioning revealed that 5.3% of mothers fed in a sleeping position, 19.8% fed after ensuring proper positioning, 6.1% avoided lying down due to choking concerns and 19.8% felt uncomfortable with it. A significant portion 48.9% of the participants preferred feeding in a sitting position even during the night.

The study revealed that post-natal mothers possess strong knowledge about breastfeeding benefits and immunization, with 92.4% planning to exclusively breastfeed. Their attitudes were positive, as they largely avoided pre-lacteal feeds and received timely breastfeeding support. Practices aligned well with guidelines, with most mothers breastfeeding exclusively in the first two weeks and adhering to immunization schedules, indicating effective implementation of the recommended infant care practices.

Discussion

Our study revealed that a significant portion of the participants were aged 21-25 years (52.7%) lived in urban areas (50.4%) and came from nuclear families (53.4%). This is consistent with Kumar A et al.,'s findings with nearly half of their participants in the 21-25 year age group. However, Kumar A et al., study noted that 54.8% of participants were unaware of the correct breastfeeding position and 10.8% believed immunization should be halted if side effects occurred.¹³ Our study found that 73.3% of participants correctly identified six months as the recommended duration for exclusive breastfeeding and 64.9% considered it sufficient. Despite these positive aspects, only 49.6% of participants received prenatal breastfeeding guidance, and 50.4% were aware of milk banks, indicating ongoing gaps in education and awareness.

Rajender Singh et al., found that 98.65% of mothers believed breast milk is the best nutrition, with a high percentage of multipara mothers breastfeeding for more than two years, but only 78% initiated breastfeeding within an hour and 40% observed correct positioning and attachment. The current study also found that 98.65% believed in the benefits of breast milk, and 78% of mothers initiated breastfeeding within an hour.¹⁴ Also, in the current study, 40% of mothers observed correct positioning. Additionally, 91% of mothers preferred increased suckling to address inadequate milk output, highlighting a proactive approach similar to Rajender Singh et al.'s study findings. Na Zhang et al., found that postpartum women had limited knowledge about human milk banks and expressed safety concerns about donor milk, which hindered its acceptance.¹⁵ In contrast, our study revealed that 50.4% of mothers were aware of milk banks, indicating better awareness regarding donor milk resources. Both studies underscore the need for enhanced education on the benefits and safety of human milk banks.

The study done by Verma M revealed that 80% of respondents knew colostrum should be fed to newborns and 92% understood that breastfeeding reduces diarrhoea risk, though 67% were unaware that exclusive breastfeeding acts as a natural contraceptive. Additionally, 90% recognized that immunization prevents disease with 81.33% aware of tetanus immunization during pregnancy and 89.33% knowing about the required two doses. All the participants demonstrated positive attitude towards complete immunization for their children, with 96.66% believing it is important and intending to follow the schedule.¹⁶

Conclusion

The study found that most postnatal mothers demonstrated good knowledge of breastfeeding and immunization, with a strong commitment to exclusive breastfeeding and timely immunization. However, gaps in awareness regarding signs of adequate feeding highlight the need for enhanced prenatal education and greater support from lactation consultants to improve feeding practices.

Ethical approval

Ethics clearance was obtained and approved from Institutional ethics committee of Bangalore Medical College & Research Institute, Bengaluru. [No. BMCRI/ EC/01/23-24].

Permission for the conduct of the study was also obtained from the Medical Superintendent of Vanivilas hospital, Department of Obstetrics and gynaecology [OBG].

Presentation at a Conference: NAMSCON 2023 at Bangalore on 08.10.2024 (Won the best oral paper presentation award)

Funding

Nil

Conflict of interest

Nil

Acknowledgements

The authors would like to thank the dean and director of Bangalore Medical College and Research Institute, Bengaluru. Karnataka. The authors wish to thank all the participants who took part in this research.