Knowledge and Practice Towards Exclusive Breastfeeding Among LactatingMothers: A Cross Sectional Study

Introduction

Breastfeeding is a natural human activity required for optimal growth and development of children during early stages of life, when all parts of the infant are growing physically, mentally and socially, requiring an optimal source of energy and nutrients to the body. 

Breastfeeding is the natural and ideal way to provide optimal food and nutrition for growth and development of infant and facilitates a strong bond between mother and child.¹

As a global health recommendation, breastfeeding should be initiated early within one hour of birth, exclusive breastfeeding for first six months of life and adequate complementary foods while continuing breastfeeding for up to two years of age or beyond should be adopted.²

The benefits of breast-feeding, are long being recognized for both mother as well as baby. Along with the decreased risk of otitis media, gastroenteritis, respiratory diseases, and necrotizing enterocolitis in infancy, breast feeding is also associated with decreased risk of obesity and hypertension later in life. Despite these benefits, prevalence of breastfeeding has remained low worldwide and only one third of infants are exclusively breastfed till six months of age.³

Poor feeding practices for infants and young children is a major cause of childhood morbidity and mortality in many developing countries.⁴

During early stage of life, malnutrition damages the health and brain development, diminishes the intelligence, educability and productivity of the children. It also leads to a heightened risk of chronic non-communicable diseases in the later life.⁵

Globally, 820,000 children’s lives could be saved under five years of age if we adopted breastfeeding recommendations provided by global health authorities.⁶

The World Health Assembly (WHA) unanimously accepted a set of six global nutrition targets (Stunting, Anemia, Low birth weight, Childhood overweight, Breastfeeding and Wasting) to improve maternal, infant and young child nutrition across the world,⁷ in 2012. Out of these six nutritional targets, exclusive breastfeeding (EBF) rate of more than 50% is to be achieved by 2025.

In India, over 34.7 million cases of diarrhea and 41,882 cases of diarrheal deaths, 2.4 million cases of acute respiratory infections and pneumonia, and 40,382 cases of obesity can be prevented, if optimal breastfeeding practices are followed.⁸

If the breastfeeding is initiated early, it can reduce 22% of neonatal mortality rate and prevent up to 20,000 mothers from breast cancer.⁸ According to NFHS-4 (2015-2016), breastfeeding within one hour of birth was initiated by only 41.65 of mothers and 54.9% exclusively breastfed their infants for six months.⁹

Despite intensive promotion and initiatives from government and non-government organizations by various programs like Baby friendly hospital initiative (BHFI), Mother’s Absolute Affection (MAA), percentage of optimal breastfeeding is still low.¹⁰

There are various factors which reduce the percentage of breastfeeding. It includes lack of understanding about the concept of breastfeeding, family pressure, social and cultural belief, lack of designated place for feeding the child, place of delivery (institutional or at home), mode of delivery (vaginal or caesarean), follow up of ANC cases, place of residence (rural or urban), and in addition, easy availability of infant formula in market and its promotion as alternative to breastfeeding.¹¹

Apart from these factors, the reasons which contribute to poor adherence to breastfeeding include misconception by the people in rural area that first milk (colostrum) is harmful and they called it as witch’s milk.¹² Insufficient milk production for the child is another misconception among the mothers and family (a good enough indicator that child is getting enough milk is if the child has six to eight wet nappies a day).¹³

With this background, the current study was designed to assess the status of knowledge and practice among the lactating mothers about exclusive breastfeeding in Bareilly District, Uttar Pradesh, India.

Material and Methods

A cross sectional, community based study was conducted, in Bareilly District, Uttar Pradesh, India, for a period of one year from November 2018 to October 2019 to assess the knowledge and practices among lactating mothers about exclusive breastfeeding. To select study subjects, multistage random sampling was used and the sample size was calculated by using a single population proportion formula N=Z² P [1-P]/d² , in which a prevalence of initiation of breastfeeding within one hour of birth was taken as 16.7% by National family health survey (NFHS-4 2015-2016),¹⁴ at 95% confidence level with 20% relative error. Total of 528 lactating mothers were selected who fulfilled the inclusion criteria.

Inclusion criteria:

1. Children who were born between 37-42 gestation weeks.

2. Mothers who had given written informed consent.

Exclusion criteria:

1. Mothers of preterm babies and multiple gestations were excluded.

2. Mothers of children having any major birth defects like congenital heart disease, cleft lip/cleft palate and Down syndrome.

3. Mothers who were having any psychological disorders.

Data was collected after taking clearance from the Institutional Ethics Committee. Study participants were explained about the purpose, benefits, anonymity and confidentiality of the study and written informed consent was obtained.

To collect the data, a pre-tested, pre-designed, validated and semi-structured schedule was used.¹⁵ It consisted of items regarding the socio demographic details and work profile, age of the child, mother, profession, educational qualification, per capita income, total family income and residence, knowledge of initiation of breastfeeding, colostrum feed, exclusive breast feeding and its duration, benefits of breastfeeding. Also data was collected about practices regarding the time of initiation of breastfeeding, frequency of breastfeeding and pre-lacteal feed.

Collected data was entered in MS Excel spread sheet, coded appropriately and later cleaned for any possible errors. Analysis was carried out using SPSS (Statistical Package for Social Studies version 23.0) for windows. Analysis was done using Pearson’s chi-square test and p-value < 0.05 was considered as statistically significant.

Results

Out of total 528 mothers, majority (42.04%) were in the age group of 21-25 years. Majority (64.74%) of the mothers were residing in rural area and 35.26% in urban area. Maximum (70.45%) were Hindus and majority (67.60%) belonged to joint families. Education characteristics revealed that majority (64.95%) of the mothers were literate and 35.04% were illiterate (Table 1).

Majority (74.40%) of mothers had vaginal delivery and most of (71.59%) the deliveries were conducted in health institutions. Out of total 528 lactating mothers, 68.60% of mothers had information about exclusive breastfeeding. Knowledge about colostrum feeding and initiation of breastfeeding within one hour of birth was found to be 60.80% and 48.10% respectively (Table 2). Till six months of age, majority (71.0%) of mothers were knowing that child should be exclusively breastfed and 91.10% mothers knew that breastfeeding should be as frequent as 8 times a day or feeding on demand. In this study, all the mothers breastfed their child. Only less than half of the mothers initiated breastfeeding within one hour of birth (43.40%) and 55.90% of mothers exclusively breastfed their children.

About three fourth (75.0%) of mothers breastfed their children on demand and nearly about fifty percent (49.80%) of mothers gave pre-lacteal feed to their children; the most common was plain water/ Ghutii (23.90%) followed by formula milk (13.70%), cow’s milk (11.40%) and butter (1.5%) (Table 3). It was found that mothers belonging to urban area had higher knowledge about colostrum and frequency of breastfeeding than mothers belonging to rural area and the difference was found statistically significant (p<0.5) (Table 4). However, the association between residence and knowledge that breastfeeding should be initiated early and duration of exclusive breastfeeding was not found statistically significant.

Table 5 shows that there was a strong association between mode of delivery and initiation of breastfeeding. It was observed that practice of initiation of breastfeeding early was adequate among mothers who had vaginal delivery as compared to mothers who had caesarean section and the difference was found statistically significant (p< 0.5). Practice about introduction of pre-lacteal feed was dominant among the mothers who had caesarean section and the association was found to be statistically significant (p < 0.5).

Discussion

As a global health recommendation, initiation of breastfeeding early within one hour of birth, exclusive breastfeeding for first six months of life is vital for proper physical, social and mental development of child.

In our study, major proportion of the mothers were in the age group of 21-25 years (42.04%). A similar finding was observed in the study conducted by Sharif M et al., (2017)⁴ in Navi Mumbai, where the majority (41.4%) of mothers were in the age group of 21-25 years. A study conducted by Chandwani H et al., (2015)⁷ and Kumar A et al., (2015)¹⁶ showed that most of the mothers belonged to Hindu religion as in our study. In present study, majority (64.74%) of the mothers were from rural area followed by urban area. Similar findings were observed in the study conducted in Bangalore by Vijayalakshmi et al., (2015)¹⁷ and by Vinutha et al., (2018)¹⁸ in Karnataka. In current study, a large proportion (67.60%) of mothers belonged to joint families, similar to a study conducted by Bobhate P S et al., (2012)¹⁹ in Thane, Maharashtra.

In this study, majority (68.60%) of the mothers were aware about exclusive breastfeeding, and 48.10% knew that breastfeeding should be initiated within one hour of birth. A study conducted by Singh J et al., (2018)²⁰ in Jalandhar, Punjab found that 91.4% of mothers had knowledge about exclusive breastfeeding and 42.8% of mothers knew that within one hour of birth breastfeeding should be initiated. An Ethiopian study also showed similar results. Even though majority (93.6%) of the mothers were aware about exclusive breastfeeding,²¹ the initiation of breastfeeding within one hour was slightly low in present study (47.9%) and a strong association was found between the mode of delivery and the initiation of breastfeeding (p< 0.5). Mothers who had caesarean section initiated delayed breastfeeding, mostly due to shifting from labor room and lack of knowledge. A study conducted by Chen C et al., (2019)²² in Sub Saharan Africa concluded that the caesarean section had a negative influence on early initiation of breastfeeding.

In present study, only 60.80% of mothers knew about colostrum. According to the study conducted by Maheshwari et al., (2010)²³ and Tiwari et al., (2009)²⁴ comparing the awareness about importance of colostrum in different parts of India, the awareness levels were found to be 58% and 90% respectively. In our study, it was found that mothers belonging to urban area had better knowledge about colostrum feeding than mothers belonging to rural area. A similar study conducted in Mangalore by Javalkar S R et al., (2018)²⁵ showed that mothers belonging to rural area had poor knowledge about colostrum and the major cause was elder’s advice, similar to our study. Hence there is a need for family based educational program regarding importance of colostrum.

Proportion of exclusive breastfeeding and initiation of breastfeeding early was poor among the mothers in the present study. Only fifty percent of mothers within one hour of birth initiated breastfeeding and exclusively breastfed for six months. A study conducted by Sharif M et al. (2017)⁴ in Navi Mumbai and by Ramola P et al., (2015)²⁶ in Manipur showed that only 35.9% & 17.5% of mothers initiated breastfeeding within one hour of birth respectively. Regarding the initiation of breastfeeding early, a statistically significant difference was found among the mothers who had vaginal and caesarean mode of delivery. Mothers who had vaginal delivery practiced the same more adequately than mothers who had caesarean section.

In present study, it was observed that about half of the mothers gave pre-lacteal feed to their children. In our study, pre-lacteal feed commonly given to infant was plain water/Ghutii followed by formula milk, cow’s milk and butter. A study conducted by Das N et al., (2013)¹ in West Bengal showed that 42.1% of mothers introduced pre-lacteal feed to their children; however, the type of pre-lacteal feed was not mentioned in the study. Investigations conducted by Kishore MS et al., (2009)²⁷ & Tundia MN et al., (2018)²⁸ observed that 51.0% and 69.05% of mothers gave pre-lacteal feed to their children respectively, with water being the most common pre-lacteal feed. The most important reason for this poor practice was family customs and beliefs. It is a common belief that the baby will look after that person who takes the baby first and gives pre-lacteal feed after birth. This study found the strong association between pre-lacteal feed practices and mode of delivery. The reason behind it being post caesarean effect of anesthesia, less maternal alertness and poor maternal skill and knowledge to initiate breastfeeding. A study conducted by Gavhane S et al., (2018)²⁹ conclude that caesarean section has a pivotal role in lowering duration of exclusive breastfeeding, delayed initiation of breastfeeding and increased risk of pre-lacteal feeding.

Conclusion

The present study focused on mother’s knowledge about exclusive breastfeeding and what they actually practice. A disparity between mother’s knowledge and practice was observed in the study. More than half of the mothers initiated complementary feeding before six months of age despite having the knowledge that exclusive breastfeeding should be done for about six months of age. Information education communication (IEC) and behavior change communication (BCC) programs are needed at individual, family and community levels since majority of the mothers discarded the colostrum due to some orthodox rituals and customs, not knowing that colostrum should be given to child.

Conflict of Interest

None.