mothers’ awareness, attitudes and practices related...
TRANSCRIPT
MOTHERS’ AWARENESS, ATTITUDES AND PRACTICES RELATED
TO EXCLUSIVE BREASTFEEDING FOR FIRST SIX MONTHS OF
INFANCY- A COMMUNITY BASED STUDY IN CHITTUR TALUK,
PALAKKAD DISTRICT.
Ms. SREEJA M
Dissertation submitted in partial fulfillment of the
Requirement for the award of
Master of Public Health
ACHUTHA MENON CENTRE FOR HEALTH SCIENCE STUDIES
SREE CHITRA TIRUNAL INSTITUTE FOR MEDICAL SCIENCES AND
TECHNOLOGY, TRIVANDRUM
Thiruvananthapuram, Kerala. India – 695011
OCTOBER 2016
Dedicated to my parents and my sister
i
Acknowledgements
Foremost, I would like to thank God Almighty for all his blessings.
I am highly grateful to my guide, Ms. VT Jissa and consider myself lucky to have had a
chance to work under her. I thank her for her excellent guidance and constant encouragement
that nurtured my growth.
I would like to convey my heartfelt gratitude to the entire faculty of AMCHSS - Dr. TK
Sundari Ravindran, Dr. P Sankara Sarma, Dr. Manju R Nair, Dr. V Raman Kutty, Dr. Ravi
Prasad Varma, Dr. KR Thankappan, Dr. Biju Soman and Dr. K Srinivasan for their support
and valuable comments during my presentations.
I express my gratitude to Dr Arlene de la Mora (Iowa University – USA) for giving me
permission to use Iowa Infant Feeding Attitude scale for my dissertation. I would also like to
thank Dr Reetha, (District Medical Officer – Palakkad) for her support during my data
collection.
I am highly thankful to all the ASHA workers, JPHN and Anganwadi workers of Chittur
taluk who provided their immense support and facilitated my data collection.
I would like to acknowledge Dr.Sreenivasan K K, Mr. Krishna Kumar, and Ms. Saranya CK
for their help during the translation of my interview schedule.
I would like to thank Dr. Neethu Suresh for her guidance and encouragement throughout my
study
Lastly, I would like to thank all my friends in MPH 2015 especially Ms. Liss Maria Scaria,
Dr. Revathi V, Dr. Ariba Peerzada, Ms. Ljimol AS and Dr. Sakeena for their valuable
suggestions and encouragement throughout the study.
“A special word of thanks to my family for their love that keeps me going.”
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DECLARATION
I hereby declare that this dissertation titled “Mothers’ awareness, attitudes and practices
related to exclusive breastfeeding for first six months of infancy-.A community based study
in Chittur taluk, Palakkad district” is the bonafide record of my original research. It has not
been submitted to any other university or institution for the award of any degree or diploma.
Information derived from the published or unpublished work of others has been duly
acknowledged in the text.
Ms.Sreeja M
Achutha Menon Centre for Health Science Studies
Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum
Thiruvananthapuram, Kerala. India -695011
October, 2016
iii
CERTIFICATE
Certified that the dissertation titled “Mothers’ awareness, attitudes and practices
related to exclusive breastfeeding for first six months of infancy - A community
based study in Chittur taluk, Palakkad district” is a record of the research work
undertaken by Ms. Sreeja M, in partial fulfillment of the requirements for the award
of the degree of “Masters of Public Health” under my guidance and supervision.
Guide:
Mrs. Jissa VT
Scientist B
Achutha Menon Centre for Health Science Studies
Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum
Thiruvananthapuram, Kerala. India -695011
October, 2016
iv
TABLE OF CONTENTS
List of tables viii -ix
List of Figures ix
Glossary of abbreviations x
Abstract xi
Chapter No Page No
CHAPTER 1 INTRODUCTION 1-17
1.1 Background of the study 1
1.2 Literature review 3-16
1.2.1 Definitions 3-4
1.2.1.1 Early initiation of breastfeeding 3
1.2.1.2 Pre lacteal feeding 3
1.2.1.3 Exclusive breastfeeding 3
1.2.1.4 Supplementary feeding 3
1.2.1.5 Complementary feeding 3
1.2.1.6 Predominant feeding 4
1.2.1.7 Partially breastfeeding 4
1.2.2 Infant feeding recommendations 4
1.2.3 Benefits of breastfeeding 5
1.2.4 Infant feeding practices 7
1.2.4.1 Initiation of breastfeeding 7
1.2.4.2 Pre lacteal feeding practices 8
1.2.4.3 Colostrum discarding practices 9
1.2.4.4 Bottle feeding practices 9
1.2.4.5 Use of pacifier 10
1.2.4.6 Exclusive breastfeeding practices 10
1.2.5 Factors influencing exclusive breastfeeding 12
1.2.5.1 Maternal factors 12
1.2.5.2 Health system factors 14
v
Chapter No Page No
1.2.5.3 Family and community factors 14
1.2.6 Awareness and attitudes of mothers regarding exclusive
breastfeeding
15
1.3 Rational for the study 16
1.4 Objectives 17
CHAPTER 2:METHODOLOGY 18-24
2.1 Study design 18
2.2 Study setting 18
2.3 Study population 18
2.4 Sample size estimation 18
2.5 Inclusion criteria 18
2.6 Exclusion criteria 19
2.7 Sample selection procedure 19
2.8 Operational definitions 21
2.8.1 Exclusive breastfeeding 21
2.8.2 Initiation of breastfeeding 21
2.8.3 Pre lacteal feeding 21
2.8.4 Post lacteal feeding 21
2.8.5 Early complementary feeding 21
2.9 Data collection technique 22
2.10 Study tool 22
2.10.1 Check list 22
2.10.2 Interview schedule 22
2.10.3 IOWA Infant Feeding Attitude Scale 22
2.11 Data collection and processing of data 23
2.12 Data storage 23
2.13 Data analysis 23
2.14
Ethical considerations 25
vi
Chapter
No
Page No
CHAPTER 3: RESULTS 26-56
3.1 Socio demographic characteristics of the participants 26
3.2 Details regarding six-twelve month old children of
participated mother
27
3.3 Mothers’ awareness regarding exclusive breastfeeding 29
3.4 Mothers attitude towards breastfeeding 34
3.5 Feeding practices of mothers 36
3.6.1 Factors associated with mothers’ awareness related to
initiation of breastfeeding
41
3.6.2 Factors associated with mothers’ awareness related to
duration of exclusive breastfeeding
43
3.6.3 Factors associated with mothers’ awareness related to
advantages of exclusive breastfeeding
44
3.6.4 Results of Logistic regression analysis 46
3.7 Factors influencing mothers’ attitudes related to
breastfeeding.
47
3.8 Factors affecting feeding practices of mothers 48-54
3.8.1 Factors associated with initiation of breastfeeding 48
3.8.2 Factors associated with pre lacteal feeding 49
3.8.3 Factors associated with post lacteal feeding 50
3.8.4 Factors associated with exclusive breastfeeding duration 51
3.8.5 Factors associated with early complementary feeding 52
3.8.6 Results of logistic regression 52
3.9
Relationship between mothers awareness and exclusive
breastfeeding practices
54
vii
Chapter
No
Page
No
3.10 Relationship between mothers attitude and exclusive
breastfeeding practices
56
CHAPTER 4: DISCUSSION AND CONCLUSION 57-66
4.1 Mothers’ awareness regarding exclusive breastfeeding and
factors related to it
57
4.2 Mothers’ attitude towards breastfeeding and factors related to
it
58
4.3 Feeding practices and factors related to it 59-64
4.3.1 Initiation of breastfeeding after delivery 59
4.3.2 Pre lacteal feeding practices 60
4.3.3 Post lacteal feeding practices 62
4.3.4 Exclusive breast feeding 62
4.4 Strengths and limitations 65
4.5 Conclusion 65
BIBLIOGRAPHY
67-79
APPENDIX
Appendix 1 Research information sheet (English)
Appendix 2 Informed consent form (English)
Appendix 3 Check list (English)
Appendix 4 Interview schedule (English)
Appendix 5 Research information sheet (Malayalam)
Appendix 6 Informed consent form (Malayalam)
Appendix 7 Check list (Malayalam)
Appendix 8 Interview schedule (Malayalam)
Appendix 9 Permission letter from DMO
Appendix 10 Institutional Ethics Committee clearance letter
viii
List of tables
Table
No
Page
No
1.1 Benefits of breastfeeding 7
2.1 List of selected panchayaths and sub centres 20
3.1 Socio demographic characteristics of the participants 27
3.2 Characteristics of children of participated mothers 28
3.3 Details of last delivery of participated mothers 29
3.4 Source of information related to breastfeeding 30
3.5 Mothers’ awareness regarding breastfeeding practices 31
3.6 Classification of participants based on the their awareness related to
initiation and duration of exclusive breast feeding
32
3.7 Mothers’ opinions regarding exclusive breast feeding 33
3.8 Attitude of mother towards breast feeding ( score on IIFAS) 34
3.9 Classification of participants based on the score on IIFAS 36
3.10 Initiation of breast feeding 36
3.11 Pre and post lacteal feeding 38
3.12 Exclusive breast feeding practices 39
3.13 Early introduction (Before six months) of complementary feeding
practices (n=228)
41
3.14 Other feeding practices 41
3.15 Factors associated with mothers’ awareness related to initiation of
breastfeeding
42
3.16 Factors associated with mothers’ awareness related to duration of
exclusive breast feeding
43
3.17 Factors associated with mothers’ awareness related to advantages of
exclusive breast feeding
44
3.18
Factors associated with mothers’ awareness on exclusive breast
feeding-Results of logistic regression analysis
46
ix
Table
No
Page
No
3.19 Factors influencing mothers attitude towards breastfeeding 47
3.20 Factors associated with initiation of breastfeeding 48
3.21 Factors associated with pre lacteal feeding practices 49
3.22 Factors associated with post lacteal feeding practices 50
3.23 Factors associated with duration of exclusive breastfeeding 51
3.24 Factors associated with early complementary feeding practices 52
3.25 Factors associated with exclusive breastfeeding practices-Results of
logistic regression analysis
52
3.26 Relationship between mothers’ awareness related to initiation of
breastfeeding and their actual practices
54
3.27 Relationship between mothers awareness related to advantages and
duration of exclusive breastfeeding and their actual practice
55
3.28 Relationship between mothers attitudes related to breastfeeding and
their actual practices
56
List of figures
Fig No Title Page no
1.1 Global trends in exclusive breastfeeding 11
2.1 Multi-stage cluster sampling procedure 19
3.1 Duration of exclusive breastfeeding 40
x
Glossary of abbreviations
AAP American Academy of Paediatrics
ASHA Accredited Social Health Activists
HMBA Human Milk Banking Association
IAP Indian Academy of Paediatrics
IIFAS IOWA Infant feeding attitude scale
IYCF Infant and young child feeding
NFHS National Family Health Survey
ORS Oral Rehydration Solution
UNICEF United Nations Children's Fund
WBTI World Breastfeeding Trends Initiative
WHO World Health Organization
xi
Abstract
Background:
Even though breast milk is the universally accepted infant feeding method, practices of pre
lacteal feeding, late initiation of breast milk, early initiation of complementary feeding are
still prevalent in many countries including India. This study assessed mothers’ awareness,
attitudes and practices regarding exclusive breast feeding up to first six months of infancy.
Methods: A community based cross sectional study was conducted among 308 mothers of
six to twelve months old infants residing in Chittur taluk, Palakkad district, Kerala.
Structured interview schedule and IOWA infant feeding attitude scale was used for data
collection. Data analysis was done using SPSS version 21.
Results: Majority of participants (83%) was aware about duration of exclusive breastfeeding
and 71 percent of participants had neutral attitude towards breastfeeding. Only 24 percent of
participants exclusively breastfed their children up to five to six months, among mothers who
were aware about duration of exclusive breastfeeding only 27.1 percent practiced exclusive
breastfeeding up to five to six months.
The information on breastfeeding received during antenatal period significantly relates with
awareness and practices of mothers. Advice from family members and insufficient breast
milk were the major reasons for nonexclusive breast feeding.
Conclusion:
Most of the identified reasons for non-adherence of exclusive breastfeeding were modifiable.
Along with awareness, the mothers and family members should be motivated to practice it.
The information regarding breastfeeding provided during antenatal period can significantly
improve the awareness and practices related to exclusive breastfeeding. Antenatal support
and counseling regarding breastfeeding should be provided as essential maternal health
services.
1
CHAPTER-1
INTRODUCTION
1.1 Background of the study
Infancy period is characterized by rapid physical growth and development (Potter and
Perry, 2008). Poor infant and young child feeding practices have been identified as major
reasons for the high burden of child hood morbidity and mortality in many developing
countries (Sholeye et al., 2015). Breastfeeding is the primary way for providing ideal food
for healthy growth and development of infants (World Health Organization, 2008).World
Health Organization recommends initiation of breastfeeding within one hour of birth,
exclusive breastfeeding for first six months of life and appropriate complementary food
with continued breastfeeding up to two years of age or beyond (World Health
Organization, 2009). These methods are the most important preventive interventions to
reduce mortality in children less than five years of age (World Health Organization,
2009). World Health Organization factsheet-2016 on infant and young child feeding
shows that over 800000 under five children’s lives could be saved every year if globally
all children are optimally breastfed (World Health Organization, 2016)
Breastfeeding is the natural feeding method and breast milk is the best milk for infants
(Datta, 2009). Breastfeeding during infancy have particular importance because it is
essential for survival, growth, development and health of infants (Joseph et al., 2012).
Breast milk provides all essential nutrients for infants less than six months of age (World
Health Organization, 2016). Exclusive breastfeeding for first six months of infancy
provides continues protection from diarrhea and respiratory tract infections (World Health
Organization, 2001). It was found that children who were breastfed for long duration had
2
less infectious morbidity and mortality, fewer dental malocclusions, and higher
intelligence than those who were breastfed for shorter duration (Verduci et al.,
2014;Victora et al., 2016).Also breastfeeding protect against overweight and diabetes in
later life (Pereira et al., 2014).
In addition, breastfeeding also has several maternal benefits. Longer durations of
breastfeeding contribute to health and well-being of mothers by reducing risk of diabetes
mellitus, ovarian cancer and breast cancer (Verduci et al., 2014). Longer duration of
breast feeding also helps for spacing pregnancies (Victora et al., 2016). Breastfeeding
helps to form emotional attachment between mother and child, this emotional bond is as
vital as the nutritional benefit received from breastfeeding (American Academy of
Pediatrics, 2011)
Despite the increased awareness regarding importance of breastfeeding across the world,
36·3 million (63%) children of less than six months old in low and middle income
countries (LMIC) were not exclusively breastfed (Sankar et al., 2015). A cross sectional
study conducted in Mango chi district, Malawi shows that exclusive breastfeeding
practice is uncommon in rural area than in urban area (Kamudoni, 2005). In India only 46
percent of infants were exclusively breastfed up to six months (NFHS, 2005). The World
Breastfeeding Trends Initiative (WBTI ) assessment in 2012 on Infant and young child
feeding (IYCF) practices policy and program indicators showed that infant feeding
practices were not improved for last two decades in India (WBTI India report, 2012).
Also there is gap exists between mothers’ knowledge and their breastfeeding practices
(Joshi et al., 2014;Nelson et al., 2015;Tuan et al., 2014).
3
1.2 Literature review
1.2.1 Definitions
1.2.1.1 Early initiation of breastfeeding
‘Early Initiation of Breastfeeding means breastfeeding all normal newborns (including
those born by caesarean section) as early as possible after birth, ideally within first hour’
(Ministry of Health and Family Welfare Gov. of India, 2013).
1.2.1.2 Pre lacteal feeding
‘A pre lacteal feed is any food except mother’s milk provided to a newborn before
initiating breastfeeding’ (Khanal. et al., 2013).
‘Pre lacteal feeding is defined as the act of giving any liquid or food item (except breast
milk) to a newborn, within the first three days after birth’ (Ogah, 2012).
1.2.1.3 Exclusive breastfeeding
‘Exclusive breastfeeding is defined as no other food or drink, not even water, except
breast milk (including milk expressed or from a wet nurse) for six months of life, but
allows the infant to receive ORS, drops and syrups (vitamins, minerals and medicines)’
(WHO, 2008).
1.2.1.4 Supplementary feeding
‘Supplementary feeds are feed given to a baby under six months old to supplement intake
of breast milk, where this is insufficient’ (UNICEF).
1.2.1.5 Complementary feeding
‘Complementary feeding is defined as the process of starting when breast milk alone is no
longer sufficient to meet the nutritional requirement of infants and therefore other foods
and liquids are needed along with breast milk’ (World Health Organization, 2008).
4
1.2.1.6 Predominant breastfeeding
‘The infant’s predominant source of nourishment has been breast milk. However, the
infant may also have received water and water-based drinks (sweetened and flavored
water, teas, infusions etc.); fruit juice; oral rehydration salts solution; drop and syrup
forms of vitamins, minerals and medicines; and ritual fluids (in limited quantities) with
the exception of fruit juice and sugar-water, no food-based fluid is allowed under this
definition’ (UNICEF).
1.2.1.7 Partially breastfeeding
‘Partial breastfeeding refers to a situation where the baby is receiving some breastfeeds
but is also being given other food or food-based fluids, such as formula milk or weaning
foods’ (UNICEF).
1.2.2 Infant feeding recommendations.
Breastfeeding is the most commonly used feeding method for infants (Kamudoni, 2005).
Exclusive breastfeeding up to first six months is the globally accepted norm for infant
feeding and it is essential for the growth and development of the infants. WHO and
UNICEF's global strategy for optimal infant feeding recommends early initiation of breast
feeding (within one hour),exclusive breastfeeding for six months (180 days),safe and
nutritionally adequate complementary feeding starting from the age of six months, with
continuing breastfeeding up to two years of age or beyond (World Health Organization,
2012). Indian Academy of Pediatrics (IAP) recommends that breastfeeding should be
introduced to mothers and other caregivers as a gold standard feeding method for infants
less than six months old (IAP and HMBA, 2015). IAP also recommends for early
initiation of skin-to-skin contact by mother and newborn including those born by
caesarean section (IAP and HMBA, 2015). Optimal infant and young child feeding
guidelines recommend by Ministry of health and family welfare, Government of India
5
emphasis on early initiation of breastfeeding (within one hour), exclusive breastfeeding
for six months, timely introduction of complementary foods, i.e. after six months,
continued breastfeeding for two years or beyond, age appropriate complementary feeding
for children six months to two year and active feeding for children during and after illness
(Ministry of Health and Family Welfare Gov. of India, 2013). American academy of
pediatrics policy statement on infant feeding reaffirms that infant feeding should not be
expressed as a lifestyle choice but rather as a fundamental health issue (American
Academy of Pediatrics, 2011).
1.2.3 Benefits of breastfeeding
One randomized control trial done on breastfeeding practices in Democratic Republic of
the Congo found that the children who were breastfed for longer periods have lower
infectious morbidity and mortality, less dental malocclusions and higher intelligence than
those children who were breast fed for shorter periods or not breast fed (Yotebieng et al.,
2015). Colostrum is also known as first vaccine given to infants which is scientifically
proven for immune protection to infants (Travasso, 2015). Breast milk alone is enough to
satisfy the nutritional needs of infants up to six months (UNICEF, 2016). One systematic
review on breastfeeding reported that risk of all-cause mortality was higher in partially or
predominantly breastfed infants compared to infants exclusively breastfed for six months.
The risk of infectious morbidity was about two fold higher in non-breastfed children as
compared to breastfed children aged up to six months (Sankar et al., 2015). Breastfeeding
provides not only health benefits but also provides economic and environmental
advantages to children, women and society (Rollins et al., 2016). A population based
birth cohort study in Brazil showed that the performance of an intelligence test was
improved among those who were breast fed for twelve months compared to those who
6
were breast fed for less than one month (Victora et al., 2015). One Follow up study done
in USA among low birth weight babies showed that prevalence of upper respiratory
symptoms was comparatively low among infants who received breast milk than infants
who received formula feeding (Blaymore et al., 2002). Human milk has the properties to
prevent several non-communicable and infectious diseases in infancy and adult hood
(Verduci et al., 2014). Longer duration of breastfeeding have protective effect on diabetes
(Yotebieng et al., 2015). One Meta-analysis done in USA on scientific publications
related to benefits of human breast milk revealed that breast milk is essential for
nutritional and non-nutritional benefits to both infant and mother (American Academy of
Pediatrics, 2011). A Study on psychosocial development and breastfeeding practices
reveals that children who are exclusively breastfeed for six months had higher level of
emotional development than those children who were never breastfeed (Lind et al., 2014).
Poor practice of breastfeeding was significantly associated with diarrhea, fever and short
and rapid breath-illnesses in infants (Haile and Biadgilign, 2015).
Cow’s milk is the widely used animal milk for infant feeding. Nutritional properties of
cow’s milk are not suitable for infants; it contains three times more protein than the
mother’s milk (Prentice, 1996). Several studies showed that use of cow’s milk in infants
less than six months can cause non communicable diseases such as diabetes mellitus,
asthma, obesity etc. in their later life (Norris, 2015; Wasmuth and kolb, 2000). A meta-
analysis done by Norris on infant and childhood diet and type 1 diabetes risk suggests that
consumption of cow’s milk in infancy can cause type 1 diabetes and diabetes auto
immunity (Norris, 2010). A case control study done in Colorado showed that early
exposure to cow's milk strongly associated with high risk marker for diabetes in
Individuals (Kostraba et al., 1993).
7
Table 1.1 Benefits of breastfeeding
For the child For the mother
Breast milk is the ideal food for infants
below six months.
Breastfeeding reduces the chance of
postpartum hemorrhage and helps in better
uterine involution
Improves cognitive and motor
development.
Reduces the risk of breast and ovarian
cancer
Protect infants from various infections such
as diarrhea, respiratory infections etc.
Faster maternal recovery in post-partum
Promotes close physical and emotional
bondage with mother
Spacing of pregnancies
(Source: Guidelines for enhancing optimal infant and young child feeding practices (2013) Government of
India)
1.2.4 Infant feeding practices
Exclusive breastfeeding up to first six months is not a widely accepted practice in
developing countries (Danso, 2014). The core indicators for assessing feeding practices of
infants under six months includes early initiation of breastfeeding and exclusive breast
feeding up to six months (World Health Organization, 2010). According to NFHS 3, 96
percent of children in India were breastfed whereas, timely initiation of breastfeeding i.e.
within one hour (25%) and prevalence of exclusive breastfeeding for infants below six
months (46%) were significantly low (NFHS 3, 2005).
1.2.4.1 Initiation of breastfeeding
Early initiation of breastfeeding is essential for the survival and development of children
(WHO. 2010). One randomized control study conducted as part of ObaapaVitA trial (trial
to assess the impact of weekly vitamin ‘A’ supplementation on maternal mortality) in
Ghana revealed that there was marked increase in the risk of neonatal mortality with
delay in initiation of breastfeeding. Initiation on breastfeeding after the first day was
8
showed 2.4 fold increased risk for neonatal mortality (Edmond et al., 2006). Motee et al
reported that 39.4 percent of participants in their study in Mauritius initiated breast milk
twenty four hours after their delivery (Motee et al., 2013). One cross sectional study done
in China also showed similar findings where 40.6 percent of respondents were unable to
initiate breastfeeding within one hour after delivery (Guo et al., 2013). Delayed initiation
of breast milk after birth results in breast engorgement (Breast engorgement is the painful
overfilling of the breasts with milk, usually caused by an imbalance between milk supply
and infant demand) thus it creates lactation problems which will force parents to use
supplementary feedings for infant (Boskabadi and Bagheri., 2015). National survey
analysis of Indonesia from 2003 and 2007 showed that initiation of breastfeeding within
one hour of birth improved from 60 percent in 2003 to 63 percent in 2007 (Titaley et al.,
2014).
A Cross sectional study conducted in Lucknow reported that only 21.37 percent of
participants were able to initiate breastfeeding within one hour after delivery (Shaili et al.,
2012). A Cross sectional study from rural areas in Bangalore revealed that 19 percent of
participants didn’t initiate breastfeeding 24 hours after delivery (Madhu et al., 2009)
1.2.4.2 Pre lacteal feeding practices
Even though breast milk is the main food for infants, practice of giving pre lacteal feed is
common in many communities (Cartagena et al., 2015;Madhu et al., 2009).
A study conducted in Ethopia showed that prevalence of giving pre lacteal feed was 28.9
percent and butter was the commonly used pre lacteal feed. Introduction of pre lacteal
feed is one of the main reasons for discontinuation of exclusive breastfeeding (Khanalet
al., 2016).
9
A cross sectional study conducted in Maharashtra in 2014 showed that giving pre lacteal
feeds such as honey, jaggery water, sugar water, castor oil are common practices. The
common belief regarding giving pre lacteal feed is that they act as laxative and cleansing
agent (Dawal, 2014). NFHS 3 report in India showed that nearly 57 percent of mother
gave something other than breast milk in the first three days after birth to their child, most
widely used pre lacteal feed is animal milk followed by honey, sugar or glucose water and
plain water (NFHS 3, 2005). A cross sectional study from northern Kerala showed that
54.5 percent participants gave zam –zam water (holy water) as pre lacteal feed (Girish et
al., 2013).
1.2.4.3 Colostrum discarding practices
A Cross sectional study conducted in Ethiopia revealed that 13.5 percent of participants
discarded colostrum and they traditionally believes that colostrum is not good for infants’
health (Legesse et al., 2015). One study from Ethiopia for assessing factors responsible
for avoidance of colostrum reported that grandmothers and untrained traditional birth
attendants were the most influencing individuals responsible for discarding the colostrum
(Legesse et al., 2015). A Cross sectional study conducted in rural areas of Bangalore
revealed that 19 percent of participants discarded colostrum (Madhu et al., 2009).
1.2.4.4 Bottle feeding practices
A cross-sectional study conducted in Brazil revealed that 33.5 percent of infants less than
twelve months were fed by bottle feeding, study also showed that both maternal related
factors (such as maternal occupation and prim parity) as well as infant related factors
(such as low birth weight, cesarean delivery, and the male sex) correlate with bottle
feeding practices (Buccini et al., 2014). A cross-sectional study conducted on Taiwan
revealed that bottle feeding might be one of the risk factors for the development of
asthma and allergic diseases in later life (Hsu et al., 2012). Rigotti et al reported that
10
bottle feeding is one of the main barriers for breastfeeding practices (Rigotti et al., 2015).
A study in Karnataka showed that practice of bottle feeding is common in rural areas,
where 46.2 percent of participants used bottle fed (Banapurmath et al., 1996). In a recent
study from Kollam district in Kerala showed that 16 percent of participants used bottle
feeding to infants before six months age (Bhattathiry and kumar, 2015).
1.2.4.5 Use of pacifier
Pacifier is a rubber or plastic nipple or teething ring given to child for suck or chew on. A
prospective cohort study conducted in New Zealand showed that daily use of pacifier
associated with early cessation of breastfeeding and reduced duration of full breastfeeding
(Maastrup, 2014;Rigotti et al., 2015;Vogel et al., 2012), In United States of America
more than 40 percent of hospitals gave pacifiers to the infants (American Academy of
Pediatrics, 2012). A cross-sectional study done in Brazil revealed that frequency of use of
pacifiers gradually decreased as with increasing age of infants (Buccini et al., 2014).
1.2.4.6 Exclusive breastfeeding practices
One recent publication (2016) in Lancet series on breastfeeding reported that practice of
breastfeeding is not only varying between individuals, social groups and health services
but also considerably vary between within and between the countries (Victora et al.,
2016).
Based on a secondary data analysis using UNICEF data base related to breastfeeding
(1995 to 2010), the prevalence of exclusive breastfeeding among infants under six months
in developing countries improved from 33 percent in 1995 to 39 percent in 2010.The
prevalence increased in most of the regions of developing countries, greatest
improvement observed in West and Central Africa where prevalence of exclusive
breastfeeding increased from 12 percent to 28 percent ( Cai et al., 2012).
11
Fig 1.1 Global trends in exclusive breastfeeding
(Source:Cai X, Wardlaw T and Brown DW (2012) Global trends in exclusive breastfeeding. International
Breastfeeding Journal 7: 12)
A Meta-analysis done by Victora et al (2016) on prevalence of exclusive breastfeeding
revealed that globally less than 37 percent of infants below six months were exclusively
breast fed up to first six months. Duration of exclusive breastfeeding was less in high
income countries as compared to low and middle income countries (Victora et al., 2016).
One study in China showed that overall 98.3 percent of infants were breastfed whereas
early initiation of breastfeeding was about 59.4 percent and only 13.6 percent infants up
to five to six month had been exclusively breast fed (Guo et al., 2013).
12
A comparison of National family and health survey 1 and 3 in India showed that overall
46.3 percent and 48.6 percent of children were exclusively breast fed in NFHS 1 and 3
respectively (Chandhiok et al., 2015.)
NFHS 3 data on exclusive breastfeeding in Kerala showed that 55 percent of infants were
exclusively breastfeed up to five months (NFHS 3, 2006). A study from southern Kerala
identified wide gap between the awareness and practice of breastfeeding, 94.5 percent of
participants knew the importance of breastfeeding whereas only 12.5 percent were
practiced exclusive breastfeeding up to six months (Nelson et al., 2015).
1.2.5 Factors influencing exclusive breastfeeding.
The factors influencing exclusive breastfeeding practices and infant feeding practices
includes maternal factors, health system factors, family and community factors and socio
economic factors (Motte et al., 2013;Njeri., 2008;Tarrent et al., 2014).
1.2.5.1 Maternal factors
A systematic review of epidemiological studies conducted in Brazil showed that maternal
factors influencing breastfeeding includes maternal age, mother’s education and type of
delivery and the study pointed out that both teenage mothers and elder mothers (those
above 35 year) had more chance to interrupt exclusive breastfeeding as compared to
younger mothers (18-35 years) (Boccioni et al., 2015).
A meta-analysis from Saudi Arabia revealed that prevalence of breastfeeding was higher
among older mothers as compared to young mothers and the study concluded that
increased maternal age significantly associated with early initiation of breastfeeding (Al
Juaid et al., 2014). In contrast a cross sectional study from India showed that children of
13
elderly mothers were less likely to breastfed than children of younger age mothers (Pal
and mukhopadhyay, 2014).
Mode of delivery is significantly associated with practice of exclusive breastfeeding;
Mother who had caesarian section tends to discontinue exclusive breastfeeding practice as
compared to mother who had normal vaginal delivery (Onah et al., 2014). A cross
sectional study from Vietnam found that mothers with cesarean delivery had huge gap
between awareness of breastfeeding and practice than the mothers with normal vaginal
delivery (Tuan et al., 2014). Delay in initiation of breastfeeding was also associated with
mode of delivery, mother who delivered by caesarian section tends to have late initiation
of breastfeeding (Earle., 2002). Based on a cohort study in USA , birth order is one of the
predictors of early initiation of breastfeeding (Sutherland et al., 2011).
The important maternal factor associated with breastfeeding also includes maternal
morbidity and maternal breast health (Absence of any lactation problems such as breast
engorgement, Insufficient breast milk etc.) (Njeri, 2008). Milk insufficiency is one of the
major factors that determine exclusive breastfeeding (Motee et al., 2013). One cross
sectional study from Iran showed that women who had breastfeeding difficulty had 2.8
times more chance to introduce formula feeding than mother who did not have difficulties
(Mortazavi et al., 2015). Another Study from Vietnam describes major barriers of breast
feeding which includes medical complications of mother, intention of feeding infant
formula at birth and breastfeeding difficulties (Tuan et al., 2014).
In a cross sectional study conducted in India, 92 percent of participants reported that
perception of insufficient milk was one of the main reasons for starting supplement
feeding (Madhu et al., 2009).
14
A study from Lebanon showed that maternal employment status was one of the main
determinants of breastfeeding practices (Hamade et al., 2013). Among mothers who were
professionals, the barriers for exclusive breastfeeding practice include work status, family
influence and mothers’ health (Hamade et al., 2013). One Study from Mauritius showed
that one of the main determents of practice of exclusive breastfeeding includes mother’s
resumption of occupation (Motee et al., 2013)
1.2.5.2 Health system factors
One randomized control trial from Hong Kong reported that giving postnatal telephonic
support regarding breastfeeding can significantly improve the exclusive breastfeeding
practices (Tarrant et al., 2014). Rollins et al, in their Meta-analysis on breastfeeding
suggested that globally, environment is not supportive for most women who want to
breastfeed (Rollins et al., 2016). A cross sectional study conducted in Vietnam showed
that delivery setting had a great influence on initiation of breastfeeding after delivery; in
their study early initiation of breastfeeding was high among mother who delivered in
tertiary care setting than community health center. The study also found that if mothers
receive breastfeeding support from a health worker during pregnancy had lower
awareness-practice gap in breastfeeding (Tuan et al., 2014).
1.2.5.3 Family and community factor
More than the neonatal and maternal problems, socio cultural believes influences use of
supplements for infant feeding (Boskabadi and Bagheri, 2015). In a qualitative study from
Ghana, it was observed that breastfeeding practice was highly influenced by women’s
family because for getting better caring and support to both infants and mothers, most of
the women will go their own house and stayed there from last trimester of pregnancy to
15
postnatal period (Seidu. ,2013). One study from Massai communities in Kenya reports
that massai culture encourages feeding of infants below six months with animal blood,
animal’s milk and bitter herbs; they also give ghee to infants with in two week (Chege et
al., 2015). A cross sectional study conducted in Vietnam revealed that gap between
awareness and practice regarding breastfeeding is small in communities where exclusive
breastfeeding is considered as a social norm (Tuan et al., 2014). A community based
study in Uttarakhand revealed that 66.03 percent of participants gave pre lacteal feed to
infants and the study found that family custom and advice of relatives were the common
reason behind this practice (Shaili,2012). One study from India showed that family rituals
and the interference of elderly mother were the main reason behind late initiation of
breast feeding (Subbiah and Jeganathan, 2012). A cross sectional study conducted in Pune
showed that strong family belief is a main reason behind use of pre lacteal feeds (Sapra et
al., 2013).
1.2.6 Awareness and attitudes of mothers regarding exclusive breastfeeding.
Mothers’ awareness and attitudes will influence their breastfeeding practice. (Mbada et
al., 2013). In a cross sectional study done in Poland, 93 percent of respondents were
aware about benefits of breastfeeding on child health (Plagens-Rotman et al., 2014). In a
Cross sectional study from Uganda, 66 percent of study population reported that
exclusive breast feeding had no disadvantage and the main advantage of breastfeeding
was reported as supplementation of essential nutrition and the main perceived
disadvantage of exclusive breastfeeding was depletion of mother’s health (Petit, 2008).
Majority of the participants (88%) in a study from South Nigeria responded that exclusive
breastfeeding makes the child to grow healthy and strong, 44.4 percent responded that it
helps in delaying pregnancy and the study point out that main limitation experienced by
16
mothers for practicing exclusive breastfeeding is time consuming and occurrence of
breast ptosis (Alade et al., 2013). Mothers from Ghana believed that breastfeeding
exclusively for six month can affect subsequent introduction of other food items
(Aryeetey and Goh, 2013). The practice of exclusive breastfeeding was higher in mothers
who believed that breast milk is sufficient to meet the infant health requirement (Desai et
al., 2014). A cross sectional study done in Nigeria to assess the relationship between
mother’s perception of exclusive breastfeeding and their actual practice reveals a fairly
good relationship (Uchendu et al., 2009). A cross sectional descriptive study from Dhaka
describes the reasons for not practicing exclusive breastfeeding which includes lack of
knowledge and perception of lack of sufficient milk (Saleh et al., 2014).
One of the study from India describes mothers perception regarding duration of
breastfeeding, 56.5 percent of participants responded that continuous breastfeed for more
than five minutes from single breast can cause soreness of the nipple and also the study
reported that 42.5 percent of study participants avoided night feeding because they
perceives that night feeding can cause colic to the baby (Subbiah and jeganathan, 2012).
1.3 Rational for the study
Even though breastfeeding is the universally accepted infant feeding norm; exclusive
breastfeeding up to six month were not widely adopted. Baby friendly hospital initiatives
launched in Kerala in 1993 for promoting exclusive breastfeeding. In 2002 Kerala
declared as world first baby friendly state. Research studies from Kerala shows that
despite this twenty year breast feeding promoting activities, rates are not improved much.
Practice of giving pre lacteal feed, late initiation of breast milk, and early initiation of
complementary feeding are still prevalent in Kerala (NFHS 3 report). Mother’s infant
feeding practices are greatly influenced by their awareness and attitude. Assessing
17
mothers’ awareness regarding infant feeding practices and associated factors will help to
identify the reason for non-adherence to exclusive breastfeeding, and this will help to plan
community sensitized breastfeeding promotional activities.
1.4 Objectives
1. To assess the awareness and attitudes of mothers regarding exclusive breast feeding.
2. To assess the feeding practices followed for infants from zero to six months.
3. To assess the factors contributing to mothers’ awareness, attitudes and practices
regarding exclusive breastfeeding for first six months of infancy.
4. To assess the relationship between mothers’ awareness, attitudes and their practices
regarding exclusive breastfeeding for first six months of infancy.
18
CHAPTER 2
METHODOLOGY
2.1 Study design
This was a community based cross sectional study among mothers of six to twelve
months old children.
2.2 Study setting
Participants were selected from seven panchayaths of Chittur taluk, Palakkad district.
Chittur taluk is situated in Kerala-Tamilnadu boarder and more than 75 percent of the
population lives in rural area. Agriculture is the lively hood of most of the adults. Tamil-
Malayalam mixed culture is seen in most part of Chittur taluk.
2.3 Study population
Study population consist of all mothers of six to twelve months old children enrolled in
maternal and child health registers in sub centers of Chittur taluk, Palakkad.
2.4 Sample size estimation
Sample size was estimated using the formula 3.84x p (1-p) / d2
where p= 56.2%
(prevalence of exclusive breastfeeding in 0-5 month old infants according to NFHS 3), d=
7% (absolute precision), design effect of 1.5 and 10% of non-response rate. Sample size
was adjusted for finite population correction for a population size of 3300 mothers and
the final sample size was rounded to 308 mothers.
2.5 Inclusion criteria
• Mothers of infants from six to twelve months old children who were willing to
participate in the study.
19
2.6 Exclusion criteria
• Mothers of infants having any serious illness including congenital deformities.
• Mothers who are having psychological illness.
• Mother who had certain disease conditions with contraindications to breastfeeding
e.g.AIDS, Breast cancer.
2.7 Sample selection procedure
The study participants were selected using multi- stage cluster sampling method.
Figure 2.1 Multi-stage cluster sampling procedure
Chittur taluk consists of 16 panchayaths. By using Open Epi version (3.03), seven
panchayaths were randomly selected from the list of panchayaths in Chittur taluk
available from Chief electoral officer’s website, Kerala, and four sub centre areas were
randomly selected from each panchayath. Eleven mothers of six month to twelve months
old children were randomly selected from maternal and child health registers available at
each sub centre. Two mothers were additionally selected randomly from each list for
substitution purpose. If one mother is not available at the first time visit, an appointment
Chittur taluk
(16
panchayaths)
7 panchayaths
selected
randomly
4 Sub centre
areas from
each
panchayath
selected
randomly
(4*7=28 sub
centre areas)
11 mothers
from each
sub centre
area selected
randomly
(28*11=308
mothers)
20
for next visit was obtained by phone call. This situation mostly occurred for working
mothers and mothers who were not came to their husband’s home after delivery. In some
clusters mothers were staying in their own home for long time usually more than seven
months after delivery. If the mother was not willing to participate in the study or if the
mother was not available at the second visit, one mother from the secondary list was
contacted and included if she was willing to participate in the study. If the substitution
exceeds more than two of the additionally selected mothers, mothers available nearest to
the last contacted mother within that sub centre area was selected until required sample
size from each cluster was obtained. Permission for assessing maternal and child health
register was obtained from District medical officer, Palakkad.
The list of selected panchayaths and corresponding selected sub-centers are given in table
2.1.
Table 2.1 List of selected panchayaths and sub centres
Sl no Name of the panchayath and selected sub
centres
Sl
No
Name of the panchayath and
selected sub center areas
I. Nallepilly II. Koduvayoor
1 Nallepilly main center 5 Vettumpully
2 Nallepilly MC 6 Vadakumuri
3 Kuttipallam 7 Kannagode
4 Annamthode 8 Kakyoor
III. Kozhinchampara IV. Kollengode
9 Mallakad 13 Anamari
10 Variyaruchalla 14 Nenmani
11 Pazhaniyarpalayam 15 Thekkumchir
12 Perumbarachalla 16 Neduman
V. Pattachery VI. Muthalamada
17 Padicharakodu 21 Kuttipadam
18 Pattachery 22 Pallam
19 Karippali 23 Parayanpallam
20 Thathamagalam 24 Chemmanampathi
VII. Puthunagaram
25 Variyathukulam
26 Palayakapadam
27 Puthunagaram
28 Puthunagaram main centre
21
The investigator approached each medical officer of concerned primary health centre or
community health centre with permission letter from district medical officer. They gave
instructions to JPHN (Junior Public Health Nurse) to provide maternal and child health
register for creating random list of mothers from each sub centre area.
2.8 Operational definitions
2.8.1. Exclusive breastfeeding
‘Exclusive breastfeeding is defined as no other food or drink, not even water, except
breast milk (including milk expressed or from a wet nurse) for six months of life, but
allows the infant to receive ORS, drops and syrups (vitamins, minerals and medicines)’
(WHO,2008).
2.8.2. Initiation of breastfeeding
Time at which first breastfed is given to the new born.
2.8.3. Pre lacteal feeding
Pre lacteal feeding is any liquid or food except mother’s milk provided to a newborn
before initiating breastfeeding.
2.8.4. Post lacteal feeding
Post lacteal feeding is any liquid or food except mother’s milk provided to a
newborn within first seven days of birth.
2.8.5. Early complementary feeding
Early complementary feeding is the introduction of any kind of solid or liquid foods to
the infants before six months.
2.9 Data collection techniques
The data were collected using structured interview schedule. The interviews were
conducted in Malayalam. Information like mothers’ awareness, attitudes and practices
regarding infant feeding for first six months were captured using the interview schedule.
22
The interviews were carried out by the principal investigator itself for all the participants.
The interviews were taken place at participant’s home with minimal distractions and
discomfort for them.
2.10 Study tool
2.10.1 Check list
A check list was used to identify the availability of eligible mothers and their willingness
to participate in the study. Their personal information like address and contact numbers
were recorded in checklist. A unique identity number was given to each participant.
2.10.2 Interview schedule for mothers
A structured Interview schedule consists of open and closed ended questions was used for
data collection. The interview schedule was translated to Malayalam and again back
translated to English until mismatches were resolved. Questions were asked about socio
demographic status, details of last delivery, details regarding infants, awareness and
attitude regarding exclusive breastfeeding practice and their feeding practices up to first
six months of infant life.
2.10.3 IOWA Infant feeding attitude scale.
‘The Iowa Infant Feeding Attitude scale (IIFAS; de la Mora, Russell, Dungy, Losch, and
Dusdieker, 1998) is a valid and reliable tool for measuring mother’s attitude towards
breastfeeding and can be used in different populations (De la mora et al., 1999 ). One
study conducted in India used IIFAS scale for measuring mothers’ attitude towards infant
feeding (Vijayalakshmi et al., 2015) which was published in International journal of
Health science. A modified form of this scale was used in a study done by Girish et al
(2015) in Kerala (Girish et al., 2015).
The Iowa Infant Feeding Attitude Scale was used to measure maternal attitudes toward
infant feeding methods (e.g., breast-feeding, formula-feeding). The scale included of 17
23
attitude items to determine level of agreement to each question. A 5-point Likert scale
from strongly dis agree to strongly agree was applied to all the questions. In these items
approximately half of the items (8 items) are favorable towards breastfeeding and the
remaining nine items are favorable towards formula-feeding. Approximately half of the
questions were negatively worded (i.e. 1, 2, 4, 6, 8, 10, 11, 14, and 17). Total IIFAS score
ranges from 17 to 85 with higher scores reflecting more positive attitudes to
breastfeeding. Total scores further classified into three: (1) positive to breastfeeding (70–
85), (2) neutral (49–69), and positive to formula feeding (17–48).
This scale was translated into Malayalam and back translated till the translated version
was matched with original version. Final corrections in the translated version were done
after conducting a pilot study among five mothers. Permission for using this scale was
obtained from IIFAS developer (Arlene de la Mora, Ph.D.)
2.11 Data collection and processing of data
The data collection period was from 10th June to 31st August 2016. A written informed
consent was obtained from all participants prior to the interview. Privacy and
confidentiality of all the participants were ensured. The data entered in SPSS version 21.
2.12 Data storage
Hard copies of interview schedule and check list and the consent forms were strictly
confined to personal locker of the principle investigator in sealed covers. Software copies
of data entry sheet stored in the computer with password encryption.
2.13 Data analysis
The analysis was done using IBM SPSS Statistics for windows Version 21.0. Descriptive
analysis was done to describe the mothers’ awareness, attitude and feeding practices.
Factors associated with mothers’ awareness, attitudes and feeding practices and relation
24
between mothers’ awareness, attitudes and exclusive breastfeeding were tested by chi
square test. Odds ratios and 95% confidence intervals were estimated using logistic
regression models.
For the analysis, the outcome variables were defined as follows
Mothers’ awareness regarding exclusive breastfeeding
Mothers’ awareness related to exclusive breastfeeding was determined by three outcome
variables
1. Mothers’ awareness related to initiation of breastfeeding
Based on the mother’s awareness related to initiation of breastfeeding after normal
or caesarean delivery, mothers’ awareness was categorized in to three.
i. Good awareness- If mothers were aware about when to initiate breastfeeding after
normal and caesarean delivery.
ii. Moderate awareness- If mothers were aware about when to initiate breast feeding
after normal or caesarean delivery.
iii. Poor awareness- If mothers were not aware about when to initiate breast feeding
after normal and caesarean delivery.
2. Mothers’ awareness related to duration of exclusive breastfeeding
This was categorized in to aware or not aware.
3. Mothers’ awareness related advantage of exclusive breastfeeding
This was defined as aware about at least one advantage or not aware about any
advantages
Mothers’ attitude towards breastfeeding
Mothers’ attitude towards breastfeeding was measured using IOWA infant feeding
attitude scale.
25
Mothers’ feeding practices up to first six months of infant life
Mothers’ feeding practices up to first six months was assessed using five outcome
variables
i. Initiation of breastfeeding after delivery (initiated within one hour / not
initiated within one hour)
ii. Pre lacteal feeding practices ( Given/not given)
iii. Post lacteal feeding practices (given/not given)
iv. Duration of exclusive breastfeeding (in months)
v. Complementary feeding practices ( started before 6 months/not started
before six months)
2.14 Ethical considerations
This study got clearance from the Institutional Ethics Committee of Sree Chitra Tirunal
Institute for Medical Sciences and Technology, Trivandrum (Reference number:
SCT/IEC/914/May-2016) before the starting the data collection.
26
CHAPTER 3
RESULTS
For obtaining estimated sample size of 308, a total of 378 households were visited. In 52
households mothers were out of station, and in 18 households the investigator couldn’t
contact mothers even after the second visit. Out of 308 mothers all of them gave consent
for the study so the response rate was 100 percent.
3.1 Socio demographic characteristics of the participated women
Table 3.1 describes the Socio demographic characteristics of the participated mothers.
Age of participated mothers ranges from 18 to 39 years with mean and standard deviation
of 26 and 3.8 respectively. Only small percentage (6.2%) of participants was educated up
to postgraduate level and there were 6.5 percent of mothers who had only primary level of
education. Majority of the participants were Hindus (74.7) and very small percentage of
participants were Christian (3.2%). Majority of the participants were home makers
(77.6%), only 9 percent of participants were earning money and 10.1 percent of
participants resigned their job after delivery for giving better care to the child. More than
50 percent of participated women’s’ monthly family income was below 5000Rs, and
nearly 25 percent of participants reported that they have difficulty in managing house
hold expenditure.
27
Table 3.1 Socio-demographic characteristics of the Participants (n=308)
Characteristics n (%)
Age group
18-25 147 (47.7)
26-30 114 (37.0)
30 Above 47 (15.3)
Educational status
Primary school level 20 (6.5)
High school level 119 (38.6)
Higher secondary level 83 (26.9)
Graduate level 67 (21.8)
Post graduate and above 19 (6.2)
Religion
Hindu 230 (74.7)
Muslim 68 (22.1)
Christian 10 (3.2)
Working status
Home maker 239 (77.6)
Working in private or government sector 14 (4.5)
Self-employed/coolie 14 (4.5)
Student 10 (3.2)
Resigned job after delivery 31 (10.1)
Monthly family income ( in INR)
Below 5000 175 (56.8)
5001-10000 79 (25.6)
10001-20000 39 (12.7)
Above 20000 15 (4.9)
Reported Difficulty in meeting monthly Expenditure
Nil 84 (27.3)
Somewhat difficult 146 (47.4)
Difficult 78 (25.3)
3.2 Details regarding six to twelve month old children of participated mothers
Table 3.2 shows details regarding six to twelve months old children of the participated
mothers. Among participated mothers three mothers have twin children. So the total
number of children is 311.
28
Table 3.2.Characteristics of children of participated mothers
Characteristics n (%*)
Age of the child
6 months 21 (6.7)
7 months 35 (11.2)
8 months 35 (11.4)
9 months 37(11.9)
10 months 49 (15.7)
11 months 56 (18.0)
12 months 78 (25.0)
Sex of the child
Male 167 (53.7)
Female 144(46.3)
Birth weight
Below 2.5 Kg 58 (18.6)
2.5-3.5 Kg 211 (67.9)
Above 3.5 Kg 42(13.5)
Birth order of the child
1 129 (41.5)
2 157 (50.5)
3 25 (8.0)
Health problem of the child during birth
Present 41(13.2)
Absent 270 (86.8)
Type of the health problem (n=41)
Meconium aspiration 3 (7.3)
Low birth weight/preterm 14 (34.1)
Neonatal jaundice 13 (31.7)
Respiratory problem 3 (7.3)
Others 8 (19.6)
*Percentage was calculated from 311.
Number of male children was slightly high. Birth weight ranges from 1.4 kg to 4.15 kg.
Nearly 19 percent children were low birth weight babies. Majority of the participated
mothers had two children (50.6%) and very small percentage of mothers had three
children (7.8%). Among participated mothers, 13 percent of their children had health
problems during birth. Neonatal jaundice and health problems related to low birth weight/
29
preterm were the main health problems experienced by the children of participated
mothers.
Table 3.3 describes details of last delivery of participants. As compared to women
delivered in government hospital, more than 15 percent were delivered in private
hospitals. More than half of the participants (58.8%) had normal vaginal delivery. Nearly
14 percent of the participants experienced health problems during delivery.
Table 3.3 Details of last delivery of participated mothers
Characteristics n (%)
Place of delivery
Government hospital 127 (41.2)
Private hospital 181 (58.8)
Mode of delivery
Normal delivery 181 (58.8)
Caesarean delivery 127 (41.2)
Problems during delivery
Present 31 (10.1)
Absent 277 (89.9)
Problem during delivery (n=31)
High blood pressure 11 (35.5)
Post-partum hemorrhage 5 (16.1)
Others 15 (48.4)
3.3 Mothers’ Awareness regarding exclusive breastfeeding
Table 3.4 describes sources of information related to breastfeeding, received by the
women. Nearly half of the participants received any kind of information related to
breastfeeding during antenatal period where as more than 90 percent of participants
received any kind of information regarding breastfeeding after delivery. During antenatal
period ASHA or Anganwadi workers mainly provided the information whereas hospital
or health centre was the major source of information after delivery. As compared to
antenatal period, more than 47 percent of participants received information regarding
breastfeeding from hospital or health center after delivery.
30
Table 3.4 Sources of information related to breastfeeding (n=308)
Characteristics n (%)
Information related to breastfeeding received during antenatal period
Yes 148 (48.1)
No 160 (51.9)
If yes, Source of information (n=148)*
Hospital/Health center 64 (43.2)
Family members 61 (41.2)
ASHA/Anganwadi worker 106 (71.6)
Friends 11 (7.4)
Relatives 14 (9.5)
Mass media 64 (43.2)
Information related to breastfeeding received After delivery
Yes 288 (93.5)
No 20 (6.5)
If yes, Source of information (n=288)*
Hospital/Health center 253 (87.8)
Family members 233 (80.9)
ASHA/Anganwadi worker 141 (49)
Friends 64 (22.1)
Relatives 11.1 (32)
Mass media 107 (37.2)
*Multiple responses possible
Table 3.5 describes mothers’ awareness regarding breastfeeding practices. Two by third
of the participants (65.2%) were aware about time of initiation of breastfeeding after
normal delivery whereas only 28 percent of the participants correctly knew about when to
initiate breastfeeding after caesarean delivery. Majority of the participants (82%) knew
that duration of exclusive breastfeeding is up to six months. About 53 percent of women
responded that mother should breastfeed the child for more than two years. Few
participants (n=4) responded that duration of breastfeeding depends on sex of the child.
They said that mothers should breastfeed male children for longer as compared to female
children because male children has to do more physical works in future as compared to
31
females , so they need more breast milk for at least 2.5 years where as for female children
1-1.5 years of Breastfeeding is sufficient.
Table 3.5 Mothers’ awareness regarding breastfeeding practices
Characteristics n (%)
Initiation of breastfeeding after normal delivery
Within 1 hr. 201 (65.3)
Within 2 hr. 26 (8.4)
Within 4 hr. 30 (9.7)
within 8 hr. 6 (1.9)
Within 24hr. 2 (0.6)
Don’t know 43 (14.0)
Initiation of breastfeeding after caesarean delivery
Within 1 hr. 87 (28.2)
Within 2 hr. 15 (4.9)
Within 4 hr. 46 (14.9)
Within 8 hr. 16 (5.2)
Within 24hr. 4 (1.3)
Don't know 140 (45.5)
Duration of exclusive breastfeeding
Up to first 2 months 2 (0.6)
Up to first 3 months 27 (8.8)
Up to first 4 months 9 (2.9)
Up to first 5 months 10 (3.2)
Up to first 6 months 255 (82.8)
Up to first 7 months 2 (0.6)
Don't know 3 (1.0)
Duration of breastfeeding
Up to 6 months 2 (0.6)
6 months to 1 year 6 (1.9)
More than 1 year to 2 year 131 (42.5)
More than 2 year 163 (52.9)
Don't know 6 (1.9)
32
Table 3.6 classifies participants based on their awareness related to initiation of
breastfeeding and duration of exclusive breastfeeding. Nearly 22 percent of participants
were aware about both initiation of breastfeeding and duration of exclusive breastfeeding
whereas nearly 8 percent of participants were not aware about these things.
Table 3.6 Classification of participants based on the their awareness related to
initiation and duration of exclusive breastfeeding (n=308)
Characteristics n (%)
Aware about initiation of breastfeeding( after normal and cesarean
delivery) and duration of exclusive breastfeeding
68 (22.1)
Aware about initiation of breastfeeding after normal or caesarean delivery
and duration of exclusive breastfeeding
111 (36.0)
Aware about duration of exclusive breastfeeding only 76 (24.7)
Aware about initiation of breastfeeding ( after normal and cesarean
delivery) only
12 (3.9)
Aware about initiation of breastfeeding after normal or caesarean delivery
but not aware about the duration of exclusive breastfeeding
17 (5.5)
Not aware about both initiation of breastfeeding and duration of exclusive
breastfeeding
24 (7.8)
Nearly 81 percent of participants were aware about at least one advantage of exclusive
breastfeeding. Majority of the participants (82.3%) said that exclusive breastfeeding
protect child from infections i.e. it provides immunity to the child. Some participants said
that early introduction of food can cause productive cough (in Malayalam kaffa kettu) to
the child. Only few of respondents (9.6%) were aware about maternal benefits of
breastfeeding. Responses regarding maternal benefits of breastfeeding were: protection
from breast cancer, birth spacing, maternal weight loss after delivery and faster maternal
recovery in postpartum. More than 75 percent of the participants commented about the
limitations of breastfeeding and few participants (8.2%) responded that exclusive
33
breastfeeding has no limitations. Mother should always be with the child, which was one
of the main limitations of exclusive breastfeeding reported by the mothers (71%). Nearly
half of the participants (41%) responded that insufficient breast milk was a limitation for
non-exclusive breastfeeding. Some participants (25.6%) reported that even though breast
milk contains adequate nutrient, which was not enough to satisfy child’s hunger as breast
milk digests quickly. Few mothers (4.6%) said that exclusive breastfeeding can reduce
child’s strength in future.
Table 3.7 Mothers’ opinions regarding exclusive breastfeeding (n=308)
Characteristics n (%)
Advantages of exclusive breastfeeding
Know at least one advantage 249 (80.8)
Don't know 59 (19.2)
Reported advantages*
Provides immunity to the child 205 (82.3)
Improves child intelligence 61 (24.5)
Suitable for infants digestive system 67 (26.9)
Good for over all child growth 53 (21.2)
Maternal benefits 24 (9.6)
Limitations of Exclusive breastfeeding
Yes 238 (77.3)
No 56 (8.2)
Don't know 14 (4.5)
Limitations of Exclusive breastfeeding*
Mother may not have sufficient milk to meet the requirement of the
infants up to six month 98 (41.2)
Breast milk is not enough to meet the nutritional demand of infants up to
six months 87 (36.6)
Exclusive Breastfeeding up to six months deplete maternal health 64 (26.9)
Child become lean 57 (23.9)
Child refuse to take other food items after six months 31 (23.9)
Child strength will reduces 11 (4.6)
* Multiple answers possible
34
3.4 Mothers’ attitude towards breastfeeding
Table 3.9 shows classification of mothers based on the score on IIFAS. Majority of the
participants (71.1) have neutral attitude towards breastfeeding and no participants (0%)
have positive attitude towards formula feeding. Mean attitude score is 66.34 with standard
deviation of 5.32. More than half of the participants (55.5%) responded that formula milk
is the better option for working women. Nearly 43 percent of the participants (42.2%)
said that mother should not breastfeed in public places. Almost 97 percent of participants
said that breast milk is the ideal food for the infants. Very few of the participants (2.3%)
responded that mother can give breast milk if they drink alcohol occasionally.
Table 3.8 Attitude of mother towards breastfeeding (Score on IIFAS)
Sl
no Components of
IIFAS
Dis agree
n (%)
Neutral
n (%)
Agree
n (%)
Mean
score(standard
deviation)
1
The benefits of breastfeeding
last only as long as the baby is
breast-fed.*
274 (88.9)
7 (2.3)
27 (8.8)
4.51 (0.949)
2 Formula feeding is more
convenient than
breastfeeding.*
289 (93.8) 3(1.0) 6 (5.2) 4.65 (0.759)
3 Breastfeeding increase
mother- infant bonding
7 (22.7) 0(0%) 301(97.7) 4.81 (0.609)
4 Breast milk lacking in iron*
146 (47.4) 133(43.2) 29 (9.4) 3.37 (0.778)
5 Formula fed babies are more
likely to be overfed than
breastfed babies
139 (45.1) 65 (21.1) 104 (33.8) 2.74 (1.181)
(Continued…)
35
Sl
no Components of
IIFAS
Dis agree
n (%)
Neutral
n (%)
Agree
n (%)
Mean
score(standard
deviation)
6 Formula feeding is the better
choice if the mother plans to
go back to work*
171 (55.5) 11 (3.5) 126 (40.9) 3.43 (1.450)
7 Mothers who formula feed
miss one of the great joys of
motherhood
57 (18.5) 8 (2.6) 176 (57.1) 4.06 (1.263)
8 Women should not breastfeed
in public places such as
restaurants*
130(42.2) 3 (2.7) 293 (95.2) 2.92 (1.39)
9 Breastfed babies are healthier
than formula fed babies
13 (4.2) 2 (0.65) 43 (14.0) 4.54 (0.771)
10 Breastfed babies are more
likely to be overfed than
formula fed babies*
171 (55.5) 94 (30.5) 53(17.2) 3.56 (1.01)
11 Fathers feel left out if a
mother breast-feeds*
232 (75.3) 23 (7.46) 53 (17.2) 3.97 (1.21)
12 Breast milk is the ideal food
for babies
6 (2.0) 3 (1.0) 299 (97.1) 4.76 (0.617)
13 Breast milk is more easily
digested than formula
10 (3.3) 6 (1.9) 298 (94.8) 4.51 (0.764)
14 Formula is as healthy for an
infant as breast milk*
267 (86.7) 11 (3.6) 30 (9.7) 4.41 (1.08)
15 Breastfeeding is more
convenient than formula
14 (4.6) 5 (1.6) 289 (93.8) 4.47 (0.794)
16 Breast milk is cheaper than
formula
36 (11.6) 23 (7.5) 249 (80.8) 4.00 (0.940)
17 A mother who occasionally
drinks alcohol should not
breastfeed her baby*
7(2.3) 28 (9.1) 273 (88.7) 1.60 (0.773)
* Negatively worded items
36
Table 3.9 Classification of participants based on the score on IIFAS (N=308)
Characteristics Score n (%)
Positive attitude towards breastfeeding 70-85 89 (28.9)
Neutral attitude towards breastfeeding 49-69 219 (71.1)
Positive attitude towards Formula feeding 17-49 0 (0%)
3.5 Feeding practices of mothers
Table 3.10 describes details regarding initiation of breastfeeding. More than half of the
participants (56.5%) could not initiated breast milk within one hour and very few of the
participants (1.9%) initiated breast milk after 24 hours due to health problems to the child.
Almost all participants (98.1%) had given colostrum to their child. Some participants
(14%) experienced difficulty in breastfeeding in which nearly half of them took treatment
for those difficulties. Major difficulty experienced in breastfeeding was insufficient breast
milk (58.1%).Other difficulties includes crackled nipple, breast pain etc. Only 17.2
percent of the participants provided exclusive breastfeeding up to six months.
Table 3.10. Initiation of breastfeeding
Characteristics n (%)
Initiation of breastfeeding
Within 1 hr. 134 (43.5)
Within 1-2 hr. 96 (31.2)
Within 2-4 hr. 48 (15.6)
Within 4-6 hr. 17 (5.5)
Within 24 hr. 7 (2.3)
More than 24 hr. 6 (1.9)
Colostrum
Given 302 (98.1)
Not given 6 (1.9)
(Continued…)
37
Characteristics
n (%)
Difficulty in breastfeeding experienced during postnatal
period
Experienced 43 (14.0)
Not Experienced 265 (86.0)
Difficulties in breastfeeding (n=43)
Insufficient breast milk 25 (58.1)
Sucking difficulties 7 (16.3)
Retracted nipple 4 (9.3)
Others 7 (16.3)
Treatment taken for breastfeeding difficulties
Yes 22 (51.2)
No 21 (48.8)
Regarding pre lacteal feeding practices,22.4 percent (n=69) of participants gave pre
lacteal feeding to their child and about 9.1 percent of participants were not sure about the
introduction of pre lacteal feeding to the child. Among those who gave pre lacteal
feeding,Zam-Zam water (52.2%) and honey (39.1%) were the mostly used pre lacteal
feedings; this was given to the child as part of religious practices whereas glucose water
(20.3%) was given from hospital due to delay in shifting of the mother to the room after
delivery. Other pre lacteal feeding includes dates, sugar, and gold rubbed water. Sixty
four (20.8%) percent of the participants gave post lacteal feedings to their child. formula
milk was the mostly used post lacteal feeding (29.7%), which was given to the child due
to insufficient breast milk for first two days. Others include tea, dry grape juice, sugar
solution, gold rubbed water and palm sugar solution.
38
Table 3.11 Pre and post lacteal feeding practices
Characteristics n (%)
Pre lacteal feeding
Yes 69 (22.4)
No 211 (68.5)
Don't know 28 (9.1)
Type of pre lacteal feed (n=69)*
Zam-Zam water 36 (52.2)
Glucose water 14 (20.3)
Honey 27 (39.1)
Plain water 4 (5.8)
Formula milk 7 (10.1)
Others 4 (5.8)
Post lacteal feeding practices
Yes 64 (20.8)
No 244 (79.2)
Type of post lacteal feed (n=64)*
Glucose water 8 (12.5)
Honey 18 (28.1)
Plain water 11 (17.2)
Cow’s milk 3(4.7)
Formula milk 19 (29.7)
Others 16 (25.0)
*Multiple responses possible
Majority of the participants (72.4%) gave exclusive breastfeeding at least for three
months, 37.7 percent of mothers exclusively breastfed their children for more than or
equal to four months, and 24 percent of the mothers exclusively breastfeed their children
for more than or equal to five months. The main reason for non-exclusive breastfeeding
was due to the advice from family members or relatives (60.8%) and 19 percent of the
participants responded that introduction of food to the child at three month was their usual
family practice. Few participants (6.7%) responded that doctors or health workers advised
them to stop exclusive breastfeeding before six months.
39
Table 3.12 Exclusive breastfeeding practices
Characteristics n (%)
Duration of exclusive breastfeeding
Up to first month 34 (11.0)
Up to second month 51 (16.6)
Up to third month 107 (34.7)
Up to fourth month 42 (13.6)
Up to fifth month 21 (6.8)
Up to sixth month 53 (17.2)
Reasons for nonexclusive breastfeeding up to six months (n=255)*
Insufficient breast milk 69 (27.1)
Child is too demanding 74 (29.0)
Night time cry 65 (25.5)
Working outside the home 24 (9.4)
Cries frequently 63 (24.7)
For getting chubby appearance 30 (11.8)
Advice from family member 155 (60.8)
Usual family practice 49 (19.2)
Advice from health worker 17 (6.7)
Others 6(2.4)
*Multiple responses possible
Table 3.13 Shows complementary feeding practices of participants, 74 percent (n=228)
introduced any kind of food to the child before the age of six months. Among those who
started complementary feeding, 92.1 percent gave cereals, which was started at an
average age of 3.5 months, and 14 percent gave formula milk to the child at an average
age of 2.5 months
Fig 3.2 shows duration of exclusive breastfeeding. Majority of the participants initiated
complementary feeding within 3-4 months. Only 24 percent of the participants gave
exclusive Breastfeeding for 5- 6 months
40
Fig 3.1 Duration of exclusive breastfeeding
Table 3.13 shows complementary feeding practices of participant, 74 percent (n=228) of
participants introduced any kind of food to the child before the age of six months. Among
them majority of the participants (92.1%) gave cereals as complementary feeding at an
average age of 3.5 months, and 14 percent participants gave formula milk to the child.
0
10
20
30
40
50
60
1-2 months 3-4 months 5-6 months
27.6%
48.4 %
24.0 %
Duration of exclusive breastfeeding
41
Table 3.13 Early introduction (Before six months) of complementary feeding
practices (n=228)
*Multiple responses possible
Table 3.14 shows certain miscellaneous feeding practices of participants which include
giving oramarunnu, gripe water and bottle feeding. Oramarunnu is a traditional herbal
mixture usually prepared in home itself. Nearly 22 percent of the participants gave
oramarunnu to their child. Bottle feeding is practiced by 6.2 percent of the participants.
Table 3.14 Other feeding practices
Type of food n (%)
Mean age in months
(Standard deviation) at
introduction.
Oramarunu 67 (21.8) 1.58±1.061
Gripe water 117 (38%) 3.02±1.304
Bottle feeding 19 (6.2%) 3.211±1.2203
3.6 Factors associated with mothers’ awareness on exclusive breastfeeding.
Factors associated with mothers’ awareness on exclusive breastfeeding was assessed
using three outcome variables such as mother’s awareness regarding initiation of
breastfeeding after delivery, duration of exclusive breastfeeding and advantages of
exclusive breastfeeding (as described in methodology).
Type of food* n (%)
Mean (Standard
deviation) in months
Fruits 23 (10.1) 3.13 (±1.217)
Cereals 210 (92.1) 3.46 (±0.969)
Cow’s milk 24 (10.5) 3.46(±1.141)
Formula milk 32 (14.0) 2.50(±1.295)
Mashed vegetables 4 (1.8) 4 (±2.00)
42
3.6.1 Factors associated with mothers’ awareness on initiation of breastfeeding
Mothers with higher educational status and who received information on breastfeeding
during antenatal period were more aware about initiation of breastfeeding and this
difference was statistically significant. Even though statically not significant, mothers
who resigned job after delivery had good awareness related to initiation of breastfeeding
as compared to housewives or working mothers.
Table 3.15 Factors associated with mothers’ awareness related to initiation of
breastfeeding
Variable Categories
Awareness regarding
initiation P value Good/Moderate Poor
Age group
0.491
18-25 98 (66.7) 49(33.3)
26-30 81 (71.1) 33(28.9)
30 above 29 (61.7) 18(38.3)
Education
0.008
Up to high school 83 (59.7) 56(40.3)
Higher secondary and
above
125 (74.0) 44(26.0)
Working status
0.259
Home maker 158 (66.1) 81(33.9)
Working mother 25 (65.8) 13(34.2)
Resigned job after
delivery
25 (80.0) 6 (19.4)
Monthly family income
0.418
Up to 10000 169 (66.5) 85(33.5)
Above 10000 39 (72.2) 15(27.8)
Birth order of the
child One
89 (69.5) 39 30.5)
0.528
Two and above 119 (66.1) 61(33.9)
Birth place Government hospital 89 (70.1)
38(29.9) 0.424
Private hospital 119 (65.7) 62(34.3)
Type of delivery
Normal 125 (69.1) 56 (30.9) 0.494
Caesarean 63 (65.4) 44 (34.6)
Percentages calculated from row totals-value<0.05 was considered as statistically significant.
43
3.6.2 Factors associated with mothers’ awareness on duration of exclusive
breastfeeding.
Table 3.6 describes factors associated with mother’s awareness on duration of exclusive
breastfeeding. Age of mother and information received in antenatal period was
significantly related with mothers’ awareness regarding duration of exclusive
breastfeeding. Mothers in the age group 26-30 years had more awareness about duration
of exclusive breastfeeding. Even though statically not significant, awareness was more
among mothers with higher educational status, birth order 2 or more, and mothers who
resigned job after delivery.
Table 3.16 Factors associated with mothers’ awareness related to duration of
exclusive breastfeeding
Variable Categories Not aware
about
duration of
EBF
Aware
about
duration
P-value
Age group
18-25 32 (21.8) 115 (78.2)
0.026
26-30 11 (9.6) 103 (90.4)
30 above 10 (21.3) 37 (78.7)
Education
Up to high school 27 (19.4) 112 (80.6) 0.306
Higher secondary 26 (15.4) 143 (84.6)
Working status
Home maker 43 (18.0) 196 (82.0)
0.503
Working mother 7 (18.4) 31 (81.6)
Resigned job after
delivery 3 (9.7) 28 (90.3)
Home maker 43 (18.0) 196 (82.0)
Monthly family income
0.608
Up to 10000 45 (17.7) 209 (82.3)
Above 10000 8 (14.8) 46 (85.2)
Birth order of the child
0.128
One 27 (21.1) 101 (78.9)
Two and above 26 (14.4) 154 (85.6)
(Continued…)
44
Variable Categories Not aware
about
duration of
EBF
Aware
about
duration
P-value
Birth place
0.137
Government hospital 17 (13.4) 110 (86.6)
Private hospital 36 (19.9) 145 (80.1)
Type of delivery
0.115
Normal 26 (14.4) 155 (85.6)
Caesarean 27 (21.3) 100 (78.7)
Information received in antenatal period
0.024 Yes 18 (12.2) 130 (87.8)
No 35 (21.9) 125 (78.1)
Percentages calculated from row totals. P-value<0.05 was considered as statistically significant.
3.6.3 Factors associated with mother’s awareness on advantages of exclusive
breastfeeding.
Mother’s education and information received in antenatal period were positively
associated with awareness regarding advantages of exclusive breastfeeding.
Table 3.17 Factors associated with mothers’ awareness on advantages of exclusive
breastfeeding
Variable Categories
Aware about
at least one
advantage
Not aware
about at least
one
advantage
P-value
Age group
0.258
18-25 117 (79.6) 30 (20.4)
26-30 97 (85.1) 17 (14.9)
30 above 35 (74.5) 12 (25.5)
Education
0.003
Up to high school 102 (73.4) 37 (26.6)
Higher secondary and
above 147 (87.0) 22 (13.0)
(Continued…)
45
Percentages calculated from row totals. P-value<0.05 was considered as statistically significant.
3.6.4 Factors associated with awareness regarding exclusive breastfeeding- Results
of Logistic regression analysis
Table 3.18 represents results of binary logistic regression analysis. The variables showed
significant associations with awareness in the bivariate analysis were only included in this
analysis. Mothers who received information regarding breastfeeding in antenatal period
were three times more likely to know when to initiate breastfeeding and two times more
Variable Categories
Aware about
at least one
advantage
Not aware
about at least
one
advantage
P-value
Working status
0.514
Home maker 190 (79.5) 49 (20.5)
Working mother 32 (84.2) 6 (15.8)
Resigned job after
delivery 27 (87.1) 4 (12.9)
Monthly family income
0.098 Up to 10000 201 (79.1) 53 (20.9)
Above 10000 48 (88.9) 6 (11.1)
Birth order of the child
One 101 (78.9) 27 (21.1) 0.466
Two and above 148 (82.2) 32 (17.8)
Birth place
0.095
Government hospital 97 (76.4) 30 (23.6)
Private hospital 152 (84.0) 29 (16.0)
Type of delivery
0.169
Normal 151 (83.4) 30 (16.6)
Caesarean 98 (77.2) 29 (22.8)
Information received in antenatal period
Yes 127 (85.8) 21 (14.2) 0.033
No 12 (76.3) 38 (23.8)
46
likely to know duration of exclusive breastfeeding as compared to mothers who didn’t
receive information regarding exclusive breastfeeding in antenatal period.
Table 3.18 Factors associated with mothers’ awareness on exclusive breastfeeding-
Results of logistic regression analysis
Variables Un adjusted
odds ratio
95%
Confidence
interval
*Adjusted
odds ratio
95%
Confidence
interval
Section 1:Factors influencing mothers’ awareness on initiation of breastfeeding
Mother's education
Up to high school 1
1
Above higher secondary 1.91 1.18-3.10 1.99 1.20-3.20
Information received during antenatal period
No 1
1
Yes 3.27 1.96-5.40 3.34 1.99-5.62
Section 2: Factors influencing mother's awareness on duration of exclusive breastfeeding
Age group of mothers
18-25 years 1 1
26-30 years 1.23 0.72-2.00 1.10 0.63-1.91
Above 30 years 0.86 0.49-1.59 0.83 0.44-1.69
Information received during antenatal period
No 1
1
Yes 3.27 1.95-5.40 3.22 1.08-3.75
Section 3: Factors influencing mother's awareness on advantages of exclusive
breastfeeding
Mother's education
Up to high school 1
1
Above higher secondary 2.42 1.35-4.35 2.44 1.35-4.40
Information received during antenatal period
No 1
1
Yes 1.88 1.04-3.39 1.09 1.04-3.45
*Variables were adjusted for each other in each section
Mothers who had higher level of education were 2.4 times more likely to be aware about
advantages of breastfeeding than mothers who had high school level of education. The
effect of information received in antenatal period was diminished when adjusted for
education (unadjusted OR=1.88 Vs adjusted OR=1.09).
47
3.7 Factors influencing mother’s attitudes related to breastfeeding.
Table 3.18 shows results of bivariate analysis. Positive attitude did not largely vary with
respect to different characteristics of women.
Table 3.18 factors influencing mother’s attitude towards breastfeeding
Variable Categories
Positive
attitude Neutral P value
Age group
0.694
18-25 39 (26.5) 108(73.5)
26-30 36 (31.6) 78 (68.4)
30 above 14 (29.8) 33 (70.2)
Education
0.833
Up to high school 41 (29.5) 98 (70.5)
Higher secondary and
above 48 (28.4) 121 (71.6)
Religion
0.392
Hindu 67 (29.1) 163 (70.9)
Muslim 21 (30.9) 47 (69.1)
Christian 1 (10.0) 9 (90.0)
Working status
0.908
Home maker 68 9(28.5) 171 (71.5)
Working mother 11 (28.9) 27 (71.1)
Resigned job after delivery 10 (32.3) 21 (67.7)
Birth place
0.73
Government hospital 81 (63.8) 46 (36.2)
Private hospital 112 (61.9) 69 (38.1)
Type of delivery
0.537
Normal 116 (64.1) 65 (35.9)
Caesarean 77 (60.6) 50 (39.4)
Information received in antenatal period
0.41 Yes 89 (60.1) 59 (39.9)
No 104 (65.0) 56 (35.0)
3.8 Factors affecting feeding practices of mothers
Factors affecting feeding practices of mothers were assessed based on the five outcome
variables such as Initiation of breastfeeding after delivery, pre lacteal feeding practices,
post lacteal feeding practices, duration of exclusive breastfeeding and complementary
feeding practices (as described in methodology)
48
3.8.1 Factors associated with initiation of breastfeeding after delivery
Factors such as birth place, type of delivery, problem related to delivery and health
problems to the child during birth were significantly related with initiation of
breastfeeding. In government hospital more than 27 percent of participants initiated
Breastfeeding within one hour as compared to private hospital.
Table 3.19 Factors associated with initiation of breastfeeding
Variable Categories
Within 1
hr. 1-2 hr.
More than 2
hr. P value
Birth place
<0.001
Government hospital 75 (59.1) 34 (26.8) 18 (14.2)
Private hospital 59 (32.6) 62 (34.3) 60 (33.1)
Type of delivery
<0.001
Normal 99 (54.7) 52 (28.7) 30 (16.6)
Caesarean 35 (27.6) 44 (34.6) 48 (37.8)
Problem related
to delivery Yes 10 (32.3) 7 (22.6) 14 (45.2)
0.028
No 7 (22.6) 89 (32.1) 64 (23.1)
health problems
to the child Yes 11 (27.5) 11 (27.5) 18 (45.0) 0.007
No 123 (45.9) 85 (31.7) 60 22.4)
Percentages calculated from row totals. P-value<0.05 was considered as statistically significant
3.8.2 Factors associated with pre lacteal feeding practice.
Nearly 30 percent of mothers with higher educational status reported pre lacteal feeding
as compared to 18 percent of mother’s with lower educational status and this difference
was found to be statistically significant. More than 50 percent of mothers in Muslim
community reported pre lacteal feeding as compared to mothers in other religions, which
was highly significant. Compared to male babies, more than 10 percent of female babies
received pre lacteal feeding
49
Table 3.20 Factors associated with pre lacteal feeding practice
Variable Categories Given Not given P value
Age group
0.238
18-25 39 (28.7) 97 (71.3)
26-30 23 (22.5) 79 (77.5)
30 above 7 (16.7) 35 (83.3)
Education
0.02
Up to high school 22 (17.9) 101 (82.1)
Higher secondary and
above 47 (29.9) 110 (70.1)
Religion
<0.0001
Hindu 36 (17.3) 172 (82.7)
Muslim 33 (53.2) 29 (46.8)
Christian 0 (0.0) 10 (100)
Sex of the child
0.045
Male 30 (19.9) 121 (80.1)
Female 39 (30.2) 90 (69.8)
Percentages calculated from row totals. P-value<0.05 were considered as statistically significant
Mothers who were not sure about the introduction of pre lacteal feeding excluded were excluded from this
table.
3.8.3 Factors associated with post lacteal feeding practice
About 33 percent of mothers who gave birth in private hospitals had given post lacteal
feeding as compared to 13 percent of mothers who gave birth in government hospitals and
this difference was found to be statistically significant. Health problem of the child and
information received in antenatal period were also significantly related with post lacteal
feeding. Considerably, a large proportion of mothers who did not receive information
during antenatal period reported post lacteal feeding compared to those who received
information during antenatal period.
50
Table 3.21 Factors associated with post lacteal feeding practice
Variable Categories Given Not given P value
Birth place
<0.0001
Government hospital 16 (13.4) 103 (86.6)
Private hospital 53 (32.9) 108 (67.1)
Type of delivery
0.213
Normal 37 (22.0) 131 (78.0)
Caesarean 32 (28.6) 80 (71.4)
Problem related to delivery
Yes 10 (34.5) 19 (65.5) 0.194
No 59 (23.5) 192 (76.5)
Health problem of the child
Yes 13 (40.6) 19 (59.4) 0.026
No 56 (22.6) 192 (77.4)
Information received in antenatal period
Yes 22 (16.1) 115 (83.9) 0.001
No 47 (32.9) 96 (67.1)
Percentages calculated from row totals. P-value<0.05 were considered as statistically significant
3.8.4 Factors associated with duration of exclusive Breastfeeding practice
Information received on breastfeeding in both antenatal and post natal period were
positively associated with exclusive breastfeeding up to five-six months. Compared to
home makers, more number of working mothers and mothers who resigned job after
delivery practiced exclusive breastfeeding up to six months though it was not statistically
significant.
51
Table 3.22 Factors associated with duration of exclusive breastfeeding practice
Percentages calculated from row totals. P-value<0.05 was considered as statistically significant
3.8.5 Factors associated with early (Before six months) introduction of
complementary feeding practices
Significantly higher proportion of mothers, who did not receive information regarding
breastfeeding in antenatal period, practiced early complementary feeding. Even though
statistically not significant, it was observed that mothers in Muslim religion early
introduced complimentary feeding as compared to mothers in other religions. Among
Mothers who reported having difficulty in managing household expenditure, the
introduction of complementary feeding was less as compared to others, though it is not
statistically significant.
Variable Categories
1-2
months
3-4
months
5-6
months P value
Working status
0.282
Home maker 68 (28.5) 120 (50.2) 51 (21.3)
Working mother 8 (21.1) 16 (42.1) 14 (36.8)
Resigned job after
delivery 9 (29.0) 13 (41.9) 9 (29.0)
Information received in antenatal period
Yes 35 (23.6) 69 (46.6) 44 (29.7) 0.05
No 50 (31.3) 80 (50.0) 30 (18.8)
Information received in postnatal period
Yes 80 (27.8) 136 (47.2) 72 (25.0) 0.22
No 5 (25.0) 13 (65.0) 2 (10.0)
52
Table 3.24 Factors associated with early complementary feeding practices
Variable Categories
Complementary
feeding started
before 6 months
Complementary
feeding started
after 6 months
P value
Religion
Hindu 165 (71.7) 65 (28.3)
0.08
Muslim 57 (83.8) 11 (16.2)
Christian 6 (60.0) 4 (40.0)
Reported difficulty in managing household expenditure
Nil 63 (75) 21 (25.0)
0.112
Somewhat difficult 114 (78.1) 32 (21.9)
Difficult 51 (65.4) 27 (34.6)
Information received in antenatal period
Yes 101 (68.2) 47 (31.8) 0.026
No 127 (79.4) 33 (20.6)
Percentages calculated from row totals. P-value<0.05 was considered as statistically significant
3.8.5Factors associated with feeding practices- Results of logistic regression analysis
Table 3.25 Factors associated with exclusive breastfeeding practices. Results of
logistic regression analysis
Variables
Un
adjusted
odds
ratio
95%
Confidence
interval
*Adjusted
odds ratio
95%
Confidence
interval
Section 1:Factors influencing initiation of breastfeeding with in 1hr.
Birth place
Private hospital 1
1
Government hospital 2.98 1.86-4.77 3.23 1.95-5.33
Type of delivery
Cesarean section 1
1
Normal delivery 3.17 1.95-5.16
3.35 1.99-5.61
(Continued…)
53
Variables
Un
adjusted
odds
ratio
95%
Confidence
interval
*Adjusted
odds ratio
95%
Confidence
interval
Child health problem during
delivery
Present 1
1
Absent 2.23 1.07-4.66 2.01 0.89-4.54
Mother health problem during delivery
Present 1
1
Absent 1.7 0.77-3.74 1.44 0.59-3.51
Section 2:Pre lacteal feeding practices
Educational status of the mother
Up to high school 1
1
Above higher secondary 1.96 1.10-3.48 1.47 1.09-3.89
Religion
Hindu 1
1
Muslim 5.4 2.94-10.05 5.59 3.1-11.50
Sex of the child
Male 1
1
Female 1.74 1.01-3.02 2.51 1.23-4.28
Birth place
Government hospital 1
1
Private hospital 3.16 1.69-5.87 2.76 1.35-5.64
Section 3 Post lacteal practices
Birth place
Government hospital 1
1
Private hospital 1.44 0.81-2.56 1.4 0.78-2.53
Child health problem during delivery
Absent 1
1
Present 3.05 1.50-6.18 3.04 1.49-6.21
Information received during antenatal period
Yes 1
1
No 1.29 0.74-2.24 1.39 0.79-2.46
*Variables were adjusted for each other in each section
*Christian religion excluded as very few participants (n=10) were belong to this group
Table 3.25 represents factors influencing exclusive breastfeeding practices. Mothers who
delivered in government hospital were three times more likely to initiate breastfeed as
compared to mothers delivered in private hospitals. Mothers who belong to Muslim
54
religion had five times higher odds to initiate pre lacteal feeding as compared to Hindu
mothers. Child health problem during birth was a major factor that determines initiation
of post lacteal feeding. Infants who were having health problem during birth had three
fold risks in initiation of post lacteal feeding as compared to infants who did not have any
birth problems.
3.9 Relationship between mothers’ awareness and exclusive breastfeeding practices
Mothers’ awareness related to exclusive breastfeeding was significantly associated with
their practice. More than half of mothers who had good or moderate level of knowledge
initiated breastfeeding in one hour compared to one by fourth of mothers who had poor
knowledge regarding initiation of breastfeeding.
Table 3.26 Relationship between mothers’ awareness related to initiation of
breastfeeding and their actual practice
Mothers’ awareness regarding initiation of
breastfeeding.
Breastfeeding practices Good/Moderate
(n=208)
Poor
(n=100) P value
Initiated within one hour 109 (52.4) 25 (25.0)
<0.001 Initiated after one hour 99 (47.5) 75 (75.0)
Percentages calculated from column totals. P-value<0.05 was considered as statistically significant
Table 3.26 shows mothers’ awareness on duration and advantages of exclusive
breastfeeding, with regard to their actual practice. Nearly 27.1% of mothers who were
aware about duration of exclusive breastfeeding practiced exclusive breastfeeding up to
5-6 months, whereas it was only 8.5% if the mothers were unaware about duration.
However the results show a wide gap between mothers’ awareness on exclusive
breastfeeding and their actual practice since majority (72.9%) of women who were aware
about duration of exclusive breastfeeding did not practice it at all.
55
Table 3.27 Relationship between mothers’ awareness related to advantages and
duration of exclusive breastfeeding and their actual practice
Feeding practices
Awareness regarding duration of
exclusive breastfeeding
Aware
(n=255)
Not aware
(n=53) P value
Exclusive breastfeeding
practices
1-2 months 68 (26.7) 17 (32.1)
0.024
3-4 months 118 (46.3) 31 (58.5)
5-6 months 69 (27.1) 5 (9.4)
Complementary feeding
0.02
Introduced before six months 182 (71.4) 46 (86.8)
Introduced after six months 73 (28.6) 7 (13.2)
Feeding practices
Awareness regarding advantages of EBF
Aware Not aware P value
Exclusive breastfeeding
practices
1-2 months 64 (25.7) 21 (35.6)
0.007
3-4 months 116 (46.6) 33 (55.9)
5-6 months 69 (27.7) 5 (8.5)
Complementary feeding
0.001
Introduced before six months 174 (69.6) 54 (91.5)
Introduced after six months 75 (30.1) 5 (8.5)
Percentages calculated for column totals. P-value<0.05 was considered as statistically significant
Relationship between attitude of mothers towards breastfeeding and exclusive
breastfeeding practice
Exclusive breastfeeding practice was slightly high among mothers who had positive
attitude towards Breastfeeding as compared to mother who had neutral attitude, though it
is not statistically significant
56
Table 4.26 Relationship between attitude of mother towards breastfeeding and
exclusive breastfeeding practice
Feeding practices Category
Attitude towards
breastfeeding
Positive Neutral P value
Exclusive breastfeeding practices
1-2 months 20 (22.5) 65 (29.7) 0.353
3-4 months 44(49.4) 105 (47.9)
5-6 months 25 (28.1) 49 (22.4)
Complementary feeding practices
Before six
months 64 (71.9) 164 (74.9)
0.589
After six
months 25 (28.1) 55 (25.1) Percentage calculated for column totals.
57
CHAPTER 4
DISCUSSION AND CONCLUSION
Exclusive breastfeeding up to first six months of infancy is a well-established
scientifically proved norm for infant feeding. The current study assessed awareness and
attitudes regarding breastfeeding as well as different aspects of infant feeding up to first
six months of infancy.
4.1 Mothers awareness regarding exclusive breastfeeding and factors related to it.
In this study, around 65 percent of participants were aware about when to initiate
breastfeeding after normal delivery whereas only 28 percent of participants were aware
about when to initiate breastfeeding after cesarean delivery. But one study done in a
tertiary care hospital in South India showed that more than 90 percent and 70 percent of
participants were aware about when to initiate breastfeeding after normal or caesarean
delivery respectively (Ekamberam et al., 2010). Majority of participants in the current
study had good awareness regarding duration of exclusive breastfeeding (82%). But
another study conducted in Kerala ,only 38 percent of participants were aware about
duration of exclusive breastfeeding (Nelson et al., 2015).Whereas similar to the present
study, higher level of awareness (82.2%) regarding duration of exclusive breastfeeding
was reported in another cross sectional study conducted in Kerala (Girish et al., 2013).
The results of the current study indicate that majority of the women in the study
population are aware about duration of exclusive breastfeeding but a large number of
women are unaware about when to initiate breastfeeding especially after a cesarean
delivery.
58
In the current study, participants reported many advantages and limitations of exclusive
breastfeeding. The main advantage of exclusive breastfeeding reported by the participants
was that exclusive breastfeeding provide immunity to the child. The major discomfort
with exclusive breastfeeding reported by mothers (71%) was that the mother should be
available to the child all the time as they need to breastfeed the child frequently so their
house hold works will be affected.
The study also showed that education and information received in antenatal period were
the most important factors associated with awareness regarding initiation of
breastfeeding. But regardless of education level, more than 80 percentof women were
aware about duration of exclusive breastfeeding and awareness on duration of exclusive
breastfeeding was significantly high among those who received information in antenatal
period. But in fact, only 48 percent of participants reported that they received information
on breastfeeding during antenatal period. The results showed the importance of providing
information regarding breastfeeding during antenatal period.
4.2 Mother’s attitude towards breastfeeding and factors related to it
Mothers’ attitude towards breastfeeding was measured by IOWA infant feeding attitude
scale. In this study majority of mothers had neutral attitude towards breastfeeding and no
participants had positive attitude towards formula feeding. Mean attitude score on IIFAS
was 66.4. Similar to this result, high mean score (68.0) on IIFAS was noted in a study
conducted in Latin mothers (Holbrook et al., 2013). In that study, about half of the
participants (58%) commented that mothers should not breastfeed in public places
whereas in a study conducted in Bangalore by Vijayalakshmi et al., in 2015 reported that
nearly 75 percent of participants in their study agreed to breastfeed in public places
(Vijayalakshmi et al., 2015). In the current study, more than 95% of participants agreed
that breast milk is healthier than formula milk and only 56 percent of participants reported
59
that formula milk is the best choice for working mothers. This finding was contradictory
to the findings from a study done in Japanese mothers, where only 35 percent of mothers
considered that breast milk is healthier than formula milk and 70 percent of participants
agreed that formula milk is the best choice for working mothers (Inoue et al., 2013).
Even though the present study did not show any significant association between attitude
of mothers and their characteristics, the scale helped to understand the attitude of mothers
in general and the their attitude towards specific components used in this scale.
4.3 Feeding practices and factors related to it.
4.3.1 Initiation of breastfeeding after delivery
In this study, only 43.5 percent of participants were able to initiate breastfeeding within
one hour of child birth. Similar finding was documented in DLHS 3(District level house
hold survey in India) where prevalence of early initiation of breastfeeding after delivery
was 40 percent and a study conducted in Kerala where prevalence of early initiation of
breastfeeding was 45 percent (Nelson et al., 2015).
The current study showed that late initiation of breastfeeding was significantly associated
with mode of delivery, place of delivery, problems related to delivery and health
problems to the child, in which, place of delivery seek more attention since there is huge
difference in the proportion of mothers initiated breastfeeding within one hour (59% VS
33%), between those who delivered in government and private hospitals. But there was
not much difference in the proportion of cesarean deliveries done in government and
private hospitals. This observation further stress the importance of monitoring practice of
breastfeeding initiation in private hospitals. Some mothers who delivered in private
hospital reported that late initiation of breastfeeding was occurred due to delay in shifting
60
of mothers after late night delivery. It was also observed from the current study that the
initiation of breastfeeding was strongly related with whether the mother had knowledge
on when to initiate breastfeeding after delivery.
4.3.2 Pre lacteal feeding practices
In this study the observed prevalence of pre lacteal feeding practice was 22.6 percent,
which is relatively high. In most studies where a high prevalence of pre lacteal feeding
was observed, defined pre lacteal feeding as the act of giving any liquid or food item
(except breast milk) to a newborn, within the first 3 days after birth (NFHS 3, 2006;Ogah,
2012).But in the current study, introduction of pre lacteal feeding was defined as anything
given to the child before initiating breast milk. Studies that were used similar definition
also showed high prevalence of pre lacteal feeding, especially studies from north India. A
cross sectional study conducted in Maharashtra by Dawal et al. in 2014 showed a
prevalence of pre lacteal feeding as 49 percent (Dawal et al., 2014).Another cross
sectional study from Uttarakhand showed 66.8 percent prevalence of pre lacteal feeding (
Shali et al.., 2016).However lower prevalence (14.8%) was noted in a cross sectional
study conducted in South India (Kanagasabapathy and Sadhasivam., 2015).
In the present study significant proportion of children whose mothers belongs to Muslim
religion received pre lacteal feeding (53%). Similar result was reported in a study
conducted by Dawal et al in Maharashtra, where 50 percent of children from Muslim
community received pre lacteal feeding (Dawal et al., 2014). Also it is observed from the
current study that more than 12 percent of higher educated mothers as compared to lower
educated mothers gave pre lacteal feeding to their child that is contradictory to the results
reported by Kanagasabapathy and Sadhasivam in Tamilnadu and Dawal et al in
Maharashtra.In those studies more than 12 percent and 30 percent lower educated mother
gave pre lacteal feeding as compared to higher educated mothers respectively. (Dawal et
61
al., 2014;Kanagasabapathy and Sadhasivam,2015).In fact, mothers’ educational status
may have fewer roles in introduction of pre lacteal feeding as they were in the delivery
room, and usually the family members give the pre lacteal feed to the infants. During data
collection it was observed that many mothers were not aware about the introduction of
pre lacteal feedings to their child (9.1%).
It was noted that significant proportion of female children received pre lacteal feeding as
compared to male children in the current study. Results of multiple logistic regression
analysis showed that the role of sex was significant even after adjusted for religion and
educational status of mothers. The stratified analysis showed that irrespective of religion
significant proportion of female children received pre lacteal feeding as compare to male
children. Some people have the belief that pre lacteal feeding will give beauty to the
child. This could be a reason for increased prevalence of pre lacteal feeding among
females.
Another interesting observation from the current study is that a higher proportion of
mothers who delivered in private hospitals had given pre lacteal feeding to their infants as
compared to mothers delivered in government hospital (32.9% vs. 13.4%). Similar
observation was also documented in a study conducted by Dawal et al in Maharashtra
where the proportion of infants received pre lacteal feeding was 52.9 percent and 37.1
percent in private and government hospitals respectively (Dawal et al., 2015 ).The reason
for low prevalence of pre lacteal feeding in government hospital may be due to better
counseling in government hospital. During data collection one Muslim lady who
delivered in Government hospital said that her parents wanted to give Zam-Zam water
and honey to her child but the nurses discouraged them from giving pre lacteal feed.
Whereas few participants who delivered in private hospital commented that nobody in the
hospital discouraged their parents from giving pre lacteal feed to the infant. Higher
62
proportion of pre lacteal feeding among those who delivered in private hospitals can also
be connected with higher proportion of late initiation of breastfeeding among those who
delivered in private hospitals. One of the reasons may be that the newborn will be hand
over to family members’ immediately after delivery and they keep infants away from
mother for longer time, and they get chance to give pre lacteal feedings to the infant.
4.3.4 Post lacteal feeding practices
Regarding post lacteal feeding, around 21 percent of the participants reported that they
gave post lacteal feedings to their children. Post lacteal feeding practice was also
observed to be significantly associated with birth place. Majority of the participants who
delivered in private hospital introduced post lacteal feeding as compared to mother who
delivered in government hospital. However when adjusted for health problem of child
during birth and information received in antenatal period, birth place was not statistically
significant (OR=1.4, 95% CI: 0.78-2.53), and health problem of the child was identified
as the significant factor related with post lacteal feeding (OR=3.04, 95% CI:1.49-6.21)
4.3.5 Exclusive breastfeeding
In this study, Majority of the participants (72.4%) practiced exclusive breastfeeding up to
three months whereas only 24 percent of the participants reported exclusive breastfeeding
for five to six months duration months. Low prevalence of exclusive breastfeeding up to
six months was documented in some other Indian studies also. One study conducted by
Vijayalakshmi et al in Banglore,the prevalence of exclusive breastfeeding up to six
months was 27 percent (Vijayalakshmi et al.,2015) and a nationwide survey conducted
by Gupta and Gupta in 2003 reported a prevalence of 26 percent for 4-6 months duration
of exclusive breastfeeding (Gupta and Gupta.,2003). However, much higher prevalence
was also reported in some other studies in India. One study conducted by Madhu et al in
rural areas of Bangalore reported that 40 percent of the children received exclusive
63
breastfeeding up to six months (Madhu et al.,2009). A study conducted in South India by
Jennifer and Muthukumar in 2015 reported that 60.8 percent of children received
exclusive breastfeeding up to six months (Jennifer and Muthukumar.,2015).Another cross
sectional study conducted by Bhattathiry and Kumari in Kollam district Kerala reported
exclusive breastfeeding up to six months as 60 percent (Bhattathiry and Kumari.,2015).
NFHS 3 report on prevalence of exclusive breastfeeding during 0-5 months in Kerala
was 56.2 percent (NFHS 3., 2005), The reasons for this much discrepancy may be due to
complexity in measurement of exclusive breastfeeding, and over reporting .One review
by Hector in 2011 illustrates the complexities in measuring breastfeeding practices. The
review suggest that it is possible to over report exclusive breastfeeding if the feeding
practice in a particular day is measured ( ie 24 hr recall method). However long term
recall method is also problematic since it is difficult to establish boundary points for
breastfeeding practice (Hector., 2011). In the current study the duration of exclusive
breastfeeding was assessed by long term recall because mothers who had six to twelve
months babies were included in this study.
Some mothers in the current study reported that they introduced fluids (Plain water, Palm
sugar water, dry grape water etc.) to the infants due to the common believe that breast
milk was not enough to meet the thirst. Among those who started complementary feeding
before six months (N=228), more than 90 percent of them introduced cereal porridge
when the child is at 3.5 months old. Several unhealthy feeding practices such as formula
milk feeding, bottle feeding practices and gripe water were also reported in this study.
Insufficient breast milk was one of the primary reasons for nonexclusive breastfeeding. A
cross sectional study conducted by Yaqub and Gul in 2013 in Islamabad also reported
similar observation (Yaqub and Gul., 2013). Majority of the mothers reported that early
introduction of complementary feeding was their family practice and majority (Nearly
64
80%) of the mothers reported that advice from family members was one of the main
reasons for non-adherence to exclusive breastfeeding. During the study, some mothers
said that even though they want to continue exclusive breastfeeding, elder women in their
family advise them to start complementary feeding if the child cries or didn’t gain weight
quickly. It shows the strong influence of family members in determining the feeding
practices of children. This observation was consistent with a qualitative study done in
Ghana (Seidu., 2013). Another reason for starting complementary feeding to the child
was that breast milk was not enough to meet the child demand up to six month (Child is
too demanding).A cross sectional study conducted in rural areas of Bangalore also
observed similar finding (Madhuet al., 2009).In the current study, information received in
antenatal period influenced duration of exclusive breastfeeding, which is similar to study
conducted in Nigeria by Ogunlesi (Ogunlesi, 2009)
However it is important to be noted that despite of having good awareness regarding
duration of exclusive breastfeeding, majority of mothers in the current study could not
practice it. Among mothers who were aware about duration of exclusive breastfeeding,
only 27% could practice exclusive breastfeeding up to 5-6 months duration. Similar to
this study, a wide gap between awareness and practices was noted in several studies
(Joshi et al., 2014;Nelson et al., 2015;Tuan et al., 2014).
Observations from the current study suggest that the mothers have awareness but due to
many reasons they are unable to practice it.
4.4 Strengths and limitations
In this study an attempt was made on assessing overall awareness, perceived
limitations and reasons for non-exclusive breastfeeding This study focused
different aspects of infant feeding up to six months.
65
Mothers’ awareness was measured after completion of their practice. It may
influence the estimates of relationship between awareness and their actual
practice.
Samples were selected from maternal child health registers of sub Centre. There
was a chance to exclude the mothers who were not enrolled in sub center.
4.5 Conclusion
It is observed that majority of participants had good awareness regarding duration of
exclusive breastfeeding (82%). But only 24 percent of the participants practiced exclusive
breastfeeding up to 5-6 months. Only 27 percent of women who were aware about
exclusive breastfeeding practiced exclusive breastfeeding for 5-6 months. Three out of
four mothers practiced early complementary feeding.
Information received in antenatal period was significantly related with mothers’
awareness regarding initiation and duration of exclusive breastfeeding, as well as with
their practice. However the study results suggest that only awareness is not enough to
determine the practice of mothers. Advice from family members and insufficient breast
milk were the major reasons reported for non-adherence of exclusive breastfeeding.
Breastfeeding awareness programmes should focus not only the mothers but also their
family members, especially those who will provide primary care during postnatal period.
Continuous breastfeeding support should be given to mothers for at least first sixth month
of infant life. If breast milk is insufficient, mothers should get advice on how to increase
breast milk production instead of recommending supplementary feeding. Supplementary
and early complementary feeding should be advised only in unavoidable situations and
encourage mothers to continue breastfeeding.
Late initiation of breastfeeding was related with birth place and type of delivery, whereas
pre lacteal feeding was related with religion, sex of the child and education of mother.
66
But Post lacteal feeding was significantly related with health problems to the child. Late
initiation of breastfeeding, pre lacteal feeding and post lacteal feedings were more
prevalent among women who delivered in Private hospitals as compared to government
hospitals. These findings suggests that breastfeeding policy for monitoring and recording
of breastfeeding initiation after delivery should be implemented as compulsory in all
hospitals, especially in private hospitals
Most of the identified reasons for non-adherence of exclusive breastfeeding were
modifiable. Along with awareness, the mothers and family members should be motivated
to practice it. The information regarding breastfeeding provided during antenatal period
can significantly improve the awareness and practice related to exclusive breastfeeding.
Antenatal support and counseling regarding breastfeeding should be provided as essential
maternal health services.
67
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Achutha Menon Centre for Health Science Studies (AMCHSS)
Sree Chitra Tirunal Institute for Medical Sciences & Technology (SCTIMST)
Trivandrum-11
Research information sheet
Mother’s awareness, attitudes and practices related to exclusive breast feeding. A
Community based study in Chittur taluk, Palakkad district.
Namaskaram, I am Sreeja M, studying for Masters of Public Health (MPH) at Achutha Menon
Centre for Health Sciences Studies, Sree Chitra Tirunal Institute for Medical Sciences and
Technology,Trivandrum. As a part of the course requirement, I am conducting a community
based study on Mother’s awareness, attitude and practices related to exclusive breast feeding. A
Community based study in Chittur taluk, Palakkad district. For this study; I would like to
conduct an interview for about 25-30 minutes.
In this study you are free to take time to answer or if you are not willing to answer, you can ask
me to skip the question. Your participation in this study is purely voluntary. You have the right
to withdraw your participation at any time during the interview without any explanation.
Though there might not be direct benefit for you from this study, the information you share will
be useful for making health policy regarding maternal and child health in future. I assure you
that all the information that you will be sharing with me will be kept highly confidential and only
used for research and publication purposes. Personal information will not be revealed to anyone
under any circumstances.
For any clarification regarding the study, you can contact me and for any queries on the
authentication of this study you can contact the Member Secretary, Institutional Ethics
Committee (IEC) of SCTIMST
Ms Sreeja M Dr.Mala Ramanathan
MPH Scholar Member Secretary AMCHSS,
AMCHSS, Trivandrum SCTIMST, Trivandrum
984659430 0471-2524234
sreejamnair05@ gmail.com [email protected]
Sl.no
APPENDIX 1
Achutha Menon Centre for Health Science Studies (AMCHSS)
Sree ChitraTirunal Institute for Medical Sciences &Technology (SCTIMST)
Trivandrum-11
Informed Consent form
I have read/heard and understood all the information provided in
the Research information sheet. By signing/putting thumb impression I confirm my voluntary
participation in this study. I understand that I can withdraw my participation at any time during
the interview without any explanation and also I understand that my identity and personal
information will be kept confidential. I have been informed who should be contacted for further
clarifications.
Signature /Thump impression of the participant
House name: Signature of witness (For verbal consent)
Place:
Sl.no
APPENDIX 2
Achutha Menon Centre for Health Science Studies (AMCHSS)
Sree ChitraTirunal Institute for Medical Sciences & Technology (SCTIMST)
Trivandrum-11
Check list
Sl.no
Name of the respondent
Address and contact number
Name of the index child. (If multiple
birth write the names of
all children)
Age of the index
child in months
Is Index child mother
present during
house visit (Yes/No)
Is mother willing to
participate? (Yes/No)
APPENDIX 3
AchuthaMenon Centre for Health Science Studies (AMCHSS)
SreeChitraTirunal Institute for Medical Sciences & Technology (SCTIMST)
Trivandrum-11
Mother’s awareness, attitudes and practices related to exclusive breast feeding. A
Community based study in Chittur taluk, Palakkad district.
Interview schedule
Interview details
Code
no
Item
G1 Participant id
G2 Name of the participant
G3
Name of the sub center are
G4
Name of the panchayath
G5
Date of the interview
G6 Remarks( if any)
Socio demographic data: I would like to know some details related to your socioeconomic background.
Sl
no
Sub
code
Item Response Remark
s
1 S01 What is your age at your last birthday?
2
S02
Up to which level have you
been educated?
Illiterate 1
Literate but no formal education 2
Primary school level (1-7th STD) 3
High school level (8-10th STD) 4
Higher secondary level 5 (11-12th STD)
Sl no
APPENDIX 4
Graduate level 6 Post graduate level and above 7
Others (Specify) ………………………… 8
3
S03
What is your religion?
Hindu 1
Muslim 2
Christian 3
Others (Specify) ……………………….4
4 S04 What is your working status at present?
Home maker 1
Working in Government sector 2
Working in private sector 3 Self-employed 4
Coolie 5
Student 6
On leave 7
Resigned the job after delivery 8 Others(specify)…………………………...9
5 S05 What is the approximate monthly income of your
family?
Below Rs 5000 1
Rs 5001- 10000 2 Rs 10001-20000 3
Rs 20001 – 30000 4
Above Rs 30000 5
6
S06
Are you able to meet the monthly house hold expenditure easily?
Yes 1
Somewhat easy 2
No 3
Details regarding index child: Now I would like to know some details related your child.
7 C01
What is the date of birth of your child (Index child)?
8 C02 Sex of the child (If it is multiple birth write the sex of the children
separately)
Male 1
Female 2
9 C03 What was your child’s birth
weight? (If it is multiple birth, writes
birth weight of the children separately)
10
C04 What is the birth order of
your child? (Name of the child)
11
C05 Did the child have any
health related problem at the time of birth?
Yes 1
No 2
Skip to
question 13 if
question 11 answer
ed as 2
12 C06 If yes, Can you tell me what the problem was?
Details regarding delivery: I would like to know some details related to your last delivery
13 D01 Where did you give birth your child?
Government hospital 1 Private hospital 2
Others 3
(specify)……………………………
14 D02 What was the type of your last delivery?
Normal delivery 1
Caesarean delivery 2
Others (specify)……………… 3
15 D03 Did you had any problems during the delivery?
Yes 1
No 2
Skip to questio
n 17 if questio
n 15 answered as 2
16 D04 If yes what was your problems?
Source of information: I would like to know your source of information regarding breast feeding
practices
17 I01 Did you receive any counseling/information on
breast feeding during antenatal period during pregnancy?
Yes 1
No 2
Skip to questio
n 19 if questio
n 17 answered as 2
18 I02 If yes which was/were the
source? (Put tick mark if any of the
listed answer given )
1 Hospital/health Centre
Yes-1 No-2
2 ASHA worker
Yes-1 No-2
3
Family members
Yes-1 No-2
4
Friends
Yes-1 No-2
5 Relatives
Yes-1 No-2
6
Media(Radio,T.V, Magazines, internet etc.)
Yes-1 No-2
7
Others (specify)
Yes-1 No-2
19 I03 Did you receive any
counseling/information on breast feeding during post natal period?
Yes 1
No 2
Skip to
question 21 if questio
n 19 answer
ed as 2
20 I04
If yes which was the source? (Put tick mark if any of the
listed answer given )
1 Hospital/health Centre
Yes-1 No-2
2
ASHA worker
Yes-1 No-2
3 Family members
Yes-1 No-2
4 Friends
Yes-1 No-2
5
Relatives
Yes-1
No-2
6
Media(Radio,T.V,
Magazines, internet etc.)
Yes-1 No-2
7
Others (specify)
Yes-1 No-2
Mother’s awareness regarding exclusive breast feeding practices: I would like to know your awareness regarding exclusive breast feeding practices.
21 A01 In your opinion what should Within one hour 1
be the appropriate time to
initiate breast feeding after
normal delivery with no
complications to both
mother and child?
Within four hour 2 Within eight hour 3
Within twenty four hours 4
Others (specify)…………………………… 5
Don’t know 88
22 A02 In your opinion what should
be the appropriate time to
initiate breast feeding after
caesarean delivery with no
complications to both
mother and child?
Within one hour 1
Within four hour 2
Within eight hour 3
Within twenty four hours 4
Others (specify)……………………………….5 Don’t know 88
23 A03 Are there any situations
where mother should not
breast feed the child?
Yes 1
No 2
Don’t know 88
Skip to questio
n 25 if question 23
answered as 2
or 88
24 A04 If yes what are those circumstances
25 A05 In your opinion if a mother
has enough breast milk,
how long should the baby
given only breast milk (not
giving water, fruit juice etc.)
First month 1
First 2 months 2 First 3 months 3
First 4 months 4
First 5 months 5
First 6 months 6
First 7 months 7 First 8 months 8
Others (specify)……………………………...9
Don’t know 88
26 A06 In your opinion how long
should the mother continue
to breast feed the baby after
starting other food also?
Up to 6 months 1
6 months - 1 year 2 1 year-2 year 3
2-3 year 4
Others (specify) 5
Don’t know 88
27 A07 In your opinion, Is there
any advantages of
exclusive breast feeding
practices for first six
months of child life?
Yes 1
No 2
Don’t know 88
Skip to
question 29 if questio
n 27 is answer
ed as 2&88
28 A08
If yes what are the
advantages?
(Put tick mark if any of the
listed answer given by the
participant)
1 Breast milk is enough to meet the
nutritional demand of infant up to six month
Yes-1 No-2
2 Provides immunity to the child
Yes-1 No-2
3 Improves child intelligence
Yes-1 No-2
4 Suitable for infant
digestive system
Yes-1
No-2
5 Helps to maternal
weight loss after delivery
Yes-1 No-2
6 Others (specify)………………………..
29 A09 In your opinion, Is there
any limitations to practice
exclusive breast feeding
practices for first six
months of child life?
Yes 1
No 2
Don’t know 88
Skip to questio
n 31 if questio
n 29 answered as 2
or 88
30 A10 If yes what are the
limitations?
(Put tick mark if any of the
listed answer given)
1 Mother may not have sufficient milk to meet the requirement of the
infants up to six month
Yes-1 No-2
3 Breast milk is not
enough to meet the nutritional demand of infant up to first six
months.
Yes-1 No-2
4 It can depletes
maternal health
Yes-1 No-2
5 Child become lean Yes-1
No-2
6 Child refuses to take other foods items after six months.
Yes-1 No-2
7 Child immunity will
reduces
Yes-1 No-2
8 Mother should be there for always with child.
Yes-1 No-2
9 Others……………………………….
Now I am going to say some statements regarding infant feeding practices. In those statements you can point out your opinion.
31
32
33
34
35
36
37
T01
T02
T03
T04
T05
T06
T07
The benefits of
breastfeeding last only as long as the baby is breast-
fed. Formula feeding is more
convenient than breastfeeding.
Breastfeeding increase
mother infant bonding
Breast milk lacking in iron
Formula fed babies are more
likely to be overfed than breastfed babies
Formula feeding is the better choice if the mother plans to
go back to work
Mothers who formula feed miss one of the great joys of
motherhood
Strong disagree
Dis agree
Neutral
al
Agree
Strong Agree
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
38
39
40
41
42
43
44
45
46
T08
T09
T10
T11
T12
T13
T14
T15
T16
Women should not breastfeed in public places
such as restaurants
Breastfed babies are healthier than formula fed
babies
Breastfed babies are more likely to be overfed than
formula fed babies
Fathers feel left out if a mother breast-feeds
Breast milk is the ideal food for babies
Breast milk is more easily digested than formula
Formula is as healthy for an infant as breast milk
Breastfeeding is more convenient than formula
Breast milk is cheaper than formula
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
47
T17
A mother who occasionally drinks alcohol should not
breastfeed her baby
1
2
3
4
5
Infant feeding practices: Now I would like to ask few questions related your infant feeding practice.
48 F01 When did you initiate
breast feeding after delivery?
Within one hour 1
Within one to two hour 2
Within two to four hour 3
Within four- six hours 4 Within 24 hours 5
Others (specify)……………………………….6
49 F02 Did you have any difficulties in breast
feeding during the postnatal period?
Yes 1
No 2
Skip to questio
n 52 if questio
n 49 answered as 2
50 F03 If yes what was your
difficulties?
51 F04 How will you resolved the problem?
52
F05 Did your child receive
anything before he/she was
first put to the breast?
Yes 1
No 2
Don’t know 88
Skip to questio
n 54 if questio
n 52 is answered as 2
0r 88
53 F06 If yes, what was/were you
given to the child?
(Tick appropriate Colum
and write reasons)
Item Response Reason for
giving this to the child
1
Zam-
Zam water
Yes-1 No-2
2
Glucose
water
Yes-1 No-2
3
Honey
Yes-1 No-2
4
Sugar
Yes-1 No-2
5
Plain water
Yes-1 No-2
6
Cow’s milk
Yes-1 No-2
7 Formula
milk
Yes-1 No-2
Others(specify)
54 F07 Did you give anything to
child within one week after
initiating breast feeding?
Yes 1
No 2
Don’t know 88
Skip to
question 56 if
question 54 is answer
ed as 2 0r 88
55 F08 If yes what was/were you given to the child?
(Tick appropriate Colum and write reasons)
Item Response Reason for
giving this to the child
1 Glucose
water
Yes-1 No-2
2
Honey
Yes-1 No-2
3 Sugar
Yes-1 No-2
4
Plain water
Yes-1 No-2
5
Cow’s
milk
Yes-1 No-2
6 Formula milk
Yes-1 No-2
Others(specify)
56 F09 Did you give Colostrum or yellow milk to the child?
(Colostrum is the first milk secreted from mammary gland)
Yes 1
No 2
57 F10 How long did you exclusively breast feed the child?
Less than one month 1 2 months 2
3 months 3
4 months 4
Skip to question 58 if
question 56 is
answered as 6
5 months 5
6 months 6
More than six months 7
or7
58
F11
If you stopped exclusive
breast feeding before six month, what was/ were the
reasons (Tick appropriate colum)
1. Insufficient breast milk Yes
1
No
2
2. Child is too demanding Yes 1
No 2
3. Night time cry Yes
1
No
2
4. Working outside the home Yes 1
No 2
5. Cries frequently Yes
1
No
2
6. For getting chubby appearance to the
baby
Yes 1
No 2
7. Advice from family members or relatives
Yes 1
No 2
8. Advice from friends Yes
1
No
2
Others (Specify)
59 F12 Did you introduce any type of food other than breast
milk with in first six month infancy?
Yes 1
No 2
Skip to questio
n 61 if question 59 is
answered as 2
60 F13 If yes, which type of food
did you introduce with in first six month?
Sl
no
Type of food Yes
1
No
2
If yes, at
which month it introduced
1 Fruit juice
2 Cereals/porridge
3 Cow’s milk
4 Formula
milk
5 Mashed vegetables/fruit
s
6 Others(specify)
61 F14 Did you gave any of the
following to the child?
Item Response If yes at which month it
was introduce
d
1.Oramarunnu
Yes-1 No-2
2.Gripe
water
Yes-1 No-2
3.Bottle feed
Yes-1 No-2
Thank you very much for your participation.
APPENDIX 5
________________________
APPENDIX 6
പരിശ ോധനോ പട്ടിക
APPENDIX 7
G1
G2
G3
G4
G5
G6
1 S01
2
S02
APPENDIX 8
3 S03
4. S04.
5. S05 Rs.
Rs.
Rs.
Rs.
Rs.
6. S06
7. C01
8. C02
9. C03
10. C04
____________
11. C05
12. C06
13. D01
14. D02
15. D03
16. D04
17 I01
18. I02
19 I03
20. I04
21 A01
22. A02
23. A03
24. A04
25. A05
26. A06
27. A07
28. A08
29 A09
30. A10
31. T01
32. T02
33. T03
34. T04
35. T05
36. T06
37. T07
38. T08
39. T09
40. T10
41. T11
42. T12
43. T13
44. T14
45. T15
46. T16
47. T17
48. F01
49. F02
50. F03
51. F04
52. F05
53. F06
54. F07
55. F08
56. F09
57. F10
58. F11
59. F12
60. F13
61. F14
PROCEEDINGS OF THE DISTRICT MEDICAL OFFICER {H).PALAKKAD.
Presbnti Dr. Reetha. K: P.
SJb Accessing rhe Matenal and Cr.d Health register [o'm Sub celtresin Ch ttur Taluk Permisslon Granted - orders issued reg:-
Read: (1)Reqlest Dated:221A412016 frcm Smt. Sreeja. N,l, lvlPH2o15Achutha lvlenon Centre for Health Science Studies,Sree Chitra Thirunal Institute for l\,4edica1 Science & Technology.
ORDER.No: C4l5319/16/DMO( H ). Pkd datbd: -04-2016
A request s received from of Smt. Sreeja. IM, Master in Public Hea th- 2015, Achutha
lvlenon Cenke for Hea th Sdience Studies, Sree Chitra Thirunal Institute Jor Medical Science
& Technology, that she is doing thesis on the toplc "l!4otheis awareness, attitudes and
practices related to exclusive breast feeding for six months oi lniancy." As part of her coLrse
Smt. Sreeja. N,4, is seeking permission for accessing the l\4aternal and Child Health (IVICH)
registers to get the address of mothers from var ous sub ;enters In Chittur Thaluk.
In these circunrstances permlssion is hereby granted to Smt. Sreeja I\,4, Master in
PLrblic Heath- 2015, Achutha Menon CentTe for Health Science Studies, Sree Chitra
Thirunal lnstitute for Med cal Science & Technology fof accessing the Maternal and Child
Health ([/]CH) reg sters to get the address of the mothers ffom var ous sub centers. Details
of Sub Centers ls encosed herewth The Super ntendent / Medical Offcer of concerned
nsllut,ors dre insr-cled ro perm t S-l Sreeja I\,4 to co-p ere he' Il^es,s
sd/-
Dr; Reetha. KP
District l\,4edlcal Off icer (H),Palakkad
ToThe Incumbent
Copy to:
1 The Superintendent/ Med cal Offlcer/ CHC/PHC/ Nallepilly/ Kozht.,)anpparclNanniode / Puthunagaram/ Koduvayur/Kollengode/Muthalamada
2.T.he Deputy Regiska|Sfee Chitra ThirLrnal Inst tute forI\/ledica Science & Technology, Th ruvanathapufam 695011.
3 trile/SF
Forwar
sup
APPENDIX 9
Selected panchayaths and sub -centres
Name of the panchayath Select€d s.ub-cenke areas
Nallepilly main center
Nallepilly MCH
Pazhaniyarpalayam
Thathanagalam
Palayakapadam
Puthunagaram main Center
t1 Vetturyr ly
l8 Vadakrmqi
l9 Kamagode
20 Kakyoc
VI Kollengode
21 Anamad
22 Nenrnmi
Thekhtodira
24 Neduoaa
vII Muthrllam.da
25 Kunipadm
26 Pallam
27 Parayanpallam
28 Chernmatrampathi
APPENDIX 10