Knowledge , Attitude and Practices of Mothers Regarding Breastfeeding in a South Indian Hospital

Study was conducted to assess the knowledge, attitude and practices of mothers attending a south Indian hospital towards breastfeeding. This cross sectional study was conducted on mothers of children, attending outpatient department of a tertiary care hospital, SRM Medical College, Tamil Nadu. They were administered a pre-designed questionnaire of twenty questions related to breastfeeding. A total of 200 mothers were interviewed over a period of two months. Though many mothers (47.5%) were illiterate their knowledge to start early breastfeeding was good (80%). However, only 34.5% initiated breastfeeding within one hour. Twenty five percentage of mothers felt that colostrum is bad and 10.5% gave prelacteals. Exclusive breastfeeding was given for six months by 72% of mothers. Cow’s milk was the most commonly used top milk (23.5%). Knowledge about weaning was good but about demand feeding was poor. Doctors were the preferred counselor (87.5%) and not enough breast milk was the main reason for discontinuing breastfeeding. Mothers had good knowledge about breastfeeding practices. But there is a gap between knowledge and practice which needs to be addressed. Doctors should play a key role in educating nursing mothers as nursing mothers rely heavily on doctors for consultation.


INTRODUCTION
Exclusive breastfeeding for six months as recommended by WHO & American Academy of Pediatrics (AAP) has a number of benefits to the growing infant.Breast milk in addition to calories and proteins contain bioactive factors like IgA, lactoferrin, K-casein, cytokines, growth factors, glutathione peroxides etc which have anti-infective, antioxidant, growth promoting properties 1 .Human milk protects from various acute and chronic conditions like diarrhea, otitis media, necrotizing enterocolitis, obesity, allergies, cancers etc avoiding hospitalizations and reducing infant mortality 2 .Breast milk improves significantly Intelligence Quotient, Brain size compared to artificial feeds 3 .
In spite of this many beneficial effects of breast milk breastfeeding rates in India are abysmally low 4 .Infant mortality rate (IMR) in India is 47/1000 live births with 1.4 million babies dying every year due to poor care and infant feeding practices.A lot of factors ranging from customs, practices, education of parents, support from family and health workers play a role in successful breastfeeding practices as recommended.Through this study we aim to assess the knowledge, attitude and practices of mothers attending our hospital regarding breast feeding.This information will help us in devising specific interventions to promote breastfeeding rates.

MATERIAL AND METHODS
After obtaining Institutional ethical clearance, we conducted this observational study in SRM hospital, Tamilnadu from November 2015 to December 2015.Two hundred mothers attending pediatrics outpatient department were randomly selected.A structured questionnaire of twenty questions was prepared based on infant and young child feeding guidelines issued by Indian government.After obtaining informed consent parents were asked to fill up this questionnaire.Illiterate mothers were interviewed by volunteers and their responses were filled up in the questionnaire.All the data were tabulated and analysed.

Questionnaire
A questionnaire for assessing knowledge, attitude and practice of mothers on breastfeeding was prepared.Most of the questions were based on the questionnaire used in the study of Sushma et al 5 and a total of twenty questions were included.

RESULTS
Table 1 shows the demographic details of parents interviewed with 55.5% of their children less than six months and equal representation from both sexes.Most of their children (59%) were born vaginally.Table 2 describes the educational status of mothers.A high percentage of them (47.5%) were illiterate.While 50.5% of mothers finished their schooling, only 2% completed their college graduation.

KAP of breastfeeding is given in table 3.
Although 80% had the knowledge to initiate breastfeeding within one hour of delivery, only 34.5% started giving breastfeeding so.A good number of parents (25%) felt that colostrum is bad and 10.5% gave prelacteals before starting breastfeeding.A satisfactory 89% of mothers gave exclusive breastfeeding and most of them (72%) for six months.Those who didn't practice exclusive breastfeeding gave mainly cow's milk (23.5%).Weaning as recommended was started from six months of age by 91.5% of mothers.They also continued breastfeeding in addition to complimentary feeds.They gave breastfeeding at hourly (24.5%), two hourly (45%) intervals or whenever required (17.5%).Table 4 caters data about breastfeeding problems and consultations.Preferred counselor for breastfeeding issues was usually a doctor (87.5%).Similarly 96% of times consultation during sickness was a doctor.Not enough breast milk (37%) was the main reason for discontinuing breastfeeding.Personal satisfaction about breastfeeding was very good for mothers (73%).

DISCUSSION
In our study almost half of the mothers who participated were illiterate but their knowledge to start early breastfeeding (80%) was good.Probable reason could be the positive impact of doctors being the preferred choice as counselors (87.5%).Since mothers also rely on doctors for consultation during sickness, doctors play an important role in promoting good breastfeeding practices by setting aside some time for health education.Just like our study Oomen et al (2009) 4 in their study found that doctor's reinforcement was an important factor for continuation of breastfeeding.
A Ghana based study 5,6 has shown that breastfeeding within one hour of delivery reduces mortality by 22%.In our study although 80% had According to Karnawat et al (2015) 7 only about 50% had correct knowledge about timing of initiation of breastfeeding.In a hospital based study in Rajasthan 8 66% of doctors preferred initiating breastfeeding on day one while 60% of nurses and 96% of class IV workers preferred on second or third day.Kumar et al (2006)  9 in their study found that 58.9% of mothers initiated breastfeeding before completion of six hours after birth.
Colostrum has been considered bad by 25% of mothers and 10% have given prelacteals like sugar, honey.This increases the chances of infection to babies.According to Yadav et al 10 two thirds of nursing mothers didn't give colostrums.15.9% of respondents in Kumar et al (2006)  9 study threw away colostrums and 40% of them gave prelacteals.43% of mothers in Ben Slama et al 11 study didn't have any knowledge about colostrum.
Eleven percentage of mothers didn't exclusively breastfeed their child and 17% of them gave breast milk exclusively only for three months.Mothers should be educated about the benefits of exclusively breastfeeding till six months.Also the fact that breastfeeding can be given ad libitum should also be taught as only 17.5% knew this.In a Delhi based study Taneja et al (2003)  12 reported that although 90.6% of mothers breastfed their infants till six months, exclusive breastfeeding was not practiced in majority (26.4%).Medhi & Mahouta  (2004) et al 13  al (1987) 8 demand feeding was preferred by 77% of lower class workers while 62% of doctors preferred timed feeding.
When top feeding was used, mothers relied on cow's milk (23.5%), formula milk (5%) and packaged milk (8.5%).Hence health education should also include appropriate and safe usage of artificial feeds.Weaning was started appropriately after six months in 91.5% of infants and breast feeding was continued even after weaning by 93.5% of mothers.Study probing further into details of weaning like type of foods, quantity and frequency which we didn't include would have been more useful.Oomen et al (2009) 4 in his study found 55% usage of formula feeds which was much higher than our study (5%).According to Karnawat et al (2015) 7 20% of all mothers had correct knowledge about weaning age and in Yadav et al's study (2004) 10 only 55% correctly practiced weaning between six to twelve months.While Taneja et al (2003) 12 showed 40% of mothers improperly weaning before infant reaches four months.
Not enough breast milk (37%) and baby didn't drink well (13%) were the main reasons for stopping breastfeeding.This could have been tackled by giving hands on practical training through lactation workshop and appropriate support by health workers during the time of need.Overall 73% of mothers were satisfied with the way they provided breastfeeding to their children.Our aim should be to reach 100% satisfaction of mothers.Oomen et al (2009) 4 similar to our study reported that perceived insufficiency of milk was the main factor behind discontinuation of breastfeeding.

Table 4 : Breast feeding problems
14ported 100% breastfeeding rates with 69.35% of it being exclusive for six months.Exclusive breast feeding rates by foreign studies were 36.8%(BenSlamaetal11) in Riyadh and 22.4% (Yesildal et al14) in Turkey.According toKarnawat et