mothers’ awareness, attitudes and practices related...

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.”

ii

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


duration of exclusive breastfeeding

43


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


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).

http://www.ncbi.nlm.nih.gov/pubmed/?term=Boskabadi%20H%5Bauth%5D

http://www.ncbi.nlm.nih.gov/pubmed/?term=Bagheri%20S%5Bauth%5D

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).

https://heapro.oxfordjournals.org/search?author1=Sarah+Earle&sortspec=date&submit=Submit

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


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)


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


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)






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)


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)


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


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


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)


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



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)


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 %


41

Table 3.13 Early introduction (Before six months) of complementary feeding

practices (n=228)


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)


0.608

Up to 10000 45 (17.7) 209 (82.3)

Above 10000 8 (14.8) 46 (85.2)


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)


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)


0.098 Up to 10000 201 (79.1) 53 (20.9)

Above 10000 48 (88.9) 6 (11.1)


One 101 (78.9) 27 (21.1) 0.466

Two and above 148 (82.2) 32 (17.8)

Birth place

0.095



Type of delivery

0.169

Normal 151 (83.4) 30 (16.6)

Caesarean 98 (77.2) 29 (22.8)


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


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



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)


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



Type of delivery

0.537

Normal 116 (64.1) 65 (35.9)

Caesarean 77 (60.6) 50 (39.4)


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)


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



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)


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


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)


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)


Yes 101 (68.2) 47 (31.8) 0.026

No 127 (79.4) 33 (20.6)


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


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


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

http://www.ncbi.nlm.nih.gov/pubmed/?term=Jennifer%20HG%5Bauth%5D

http://www.ncbi.nlm.nih.gov/pubmed/?term=Muthukumar%20K%5Bauth%5D

http://www.ncbi.nlm.nih.gov/pubmed/?term=Jennifer%20HG%5Bauth%5D

http://www.ncbi.nlm.nih.gov/pubmed/?term=Muthukumar%20K%5Bauth%5D

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

mailto:[email protected]


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


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


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


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

[email protected] [email protected]



________________________

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