Assessing the Infant Breastfeeding experience of Women in Cuddalore District of Tamilnadu, India

Suganya Sweetlin P*1, Palanivel R M2, Kamala S3, Vinoth R2, Esther Prema S1, Muhil Sakthivel4, Vijay Amirtharaj S5, Sudha V6 1Department of Paediatric Nursing, Arunai Institute of Nursing Education and Research, Then Mathur, Tiruvannamalai, Tamilnadu, India 2Quality Measurement and Evaluation Department, Deanship of Quality and Academic Accreditation, Imam Abdulrahman Bin Fisal University, P.O. Box 1982, Dammam 31441, Saudi Arabia 3Department of Paediatrics, Rani Meyyamai College of Nursing, Annamalai University, Annamalai Nagar, Chidambaram, Tamilnadu, India 4Measurement & Evaluation Unit, Of ice of Vice Presidency for Graduate Studies & Scienti ic Research, Imam Abdulrahman Bin Faisal University, P.O. Box 1982, Dammam 31441, Saudi Arabia 5Department of Statistics, Periyar Arts College, Silver Beach Rd, Devanampattinam, Cuddalore, Tamil Nadu, India 6Department of Physical Education, Immaculate College of Arts and Science for Women, No.4, Bharathi Road, Cuddalore, Tamilnadu, India


INTRODUCTION
Breastfeeding is an effective way that provides the best nutrition for a baby in the irst six months of life. Being a natural phenomenon, it provides several bene its to the mother and infant. It de ines no socioeconomic boundaries and has similar nutritional content to all infants across the globe. The breastfeeding stimulates the baby's immune systems, prevent diarrhea and acute respiratory infections among infants, and enhances the response to vaccinations (Dennis, 2002). The breastfeeding practices support a child's overall development, including cognitive, psychosocial, and emotional development (Quinn et al., 2001). Moreover, breastfeeding makes a special bond between mother and baby and delivers a unique interaction and stimulation along with the balance of protein and energy and micronutrients. It aids growth and development and provides a sense of well-being and security. Besides, it supports the mother's health by aiding the uterus to contract soon after delivery, thus decreasing chances of prolonged bleeding. It decreases the mother's risk of ovarian and breast cancer.
World Health Organization (WHO) has recommended the mothers to provide exclusively breastfeeding for infants during their irst six months of life, followed by breastfeeding with complementary foods for up to two years of age or beyond (Hanif, 1990). Exclusive breastfeeding is meant as a practice through which the infants receive only breast milk and not even water, other liquids, tea, herbal preparations, or food during their the irst six months of life, except vitamins, mineral supplements, or medicine (Nkala and Msuya, 2011).The main advantage of exclusive breastfeeding from 4 to 6 months is observed as the reduction in morbidity that results from gastrointestinal infection (Kramer and Kakuma, 2002).
The chief cause of death among children under ive in India is neonatal diarrhoea, sepsis and pneumonia and breast milk is protective against these three diseases (Kumar et al., 2015). Greater than 15% of death in 24 lakhs children can be avoided in India by counselling services on infant and young child feeding (Ekambaram et al., 2010). Regardless of the knowledge of the bene its of breastfeeding, its duration and prevalence among the general population in several countries are still lower than the international recommendations of six months of exclusive breastfeeding (Mbada et al., 2013). The prevalence of exclusive six months duration breastfeeding is 46.4%, and in India, the early initiation of breastfeeding is less than 41% which is far away from the desired level and interestingly breastfeeding practices vary among different communities and regions (Statistics, 2015).
In recent years, there is a decline in breastfeeding worldwide due to urbanization and maternal employment outside the home. Studies in India have also revealed that there is a decline in breastfeeding trends, particularly in urban areas (Rasania et al., 2003). Breastfeeding dif iculties are common in lactating mothers. The common breastfeed-ing problems among women include fatigue, feeling tired, sore nipple, engorgement, dif iculty in latching on, fussy baby, and an insuf icient supply of breast milk (Mehrparvar and Varzandeh, 2008). It is also found that most of the women discontinue breastfeeding earlier due to perceived problems such as pain, leakage, unsuccessful breast attachment, lack of milk, their baby is unable to suckle, and so on (Dennis, 2002) Women perceive most of the breastfeeding problems as a relatively healthy experience, (Giugliani, 2004) though those problems could be stressful due to the degree of severity (Mozingo et al., 2000) Such problems have been revealed as risk factors breastfeeding discontinuation (Almqvist-Tangen et al., 2012).
Furthermore, breastfeeding practice is highly in luenced by various cultural, social, and religious beliefs and maternal-infant feeding attitudes. Among these factors, maternal-infant feeding attitude is observed as a critical factor of initiation of breastfeeding among women (Scott et al., 2004). Additionally, it is observed that a positive attitude towards breastfeeding is related to the continuation of breastfeeding for a more extended period and possess a high chance of success (Chen and Chi, 2003). In contrast, women with negative attitudes towards breastfeeding are considered to be the primary barrier to initiate and to continue breastfeeding (Premani et al., 2011). Pakistan has discovered the experience regarding initiating and maintaining breastfeeding among lactating women. The results identi ied the factors such as mothers' knowledge, breastfeeding decision, sociocultural background, self-motivation, and professional support after delivery that supported the initiating and maintaining of breastfeeding among lactating women. On the other hand, barriers perceived by lactating women for initiating and maintaining breastfeeding include physiological changes, sociocultural environment, time management, and role of housewife.
Previous studies have demonstrated the importance of breastfeeding as well as problems resulting from breastfeeding among lactating mothers. Researchers also stated that a negative attitude towards breastfeeding and dif iculties from breastfeeding would make mothers discontinue breastfeeding, thereby increasing the prevalence of health problems in infants. Therefore, it is essential to understand the breastfeeding experience and breastfeeding problems to prevent the discontinuation of breastfeeding and health issues among infants. In this regard, this study is intended to study the infant breastfeeding experience of women in Cuddalore district, Tamilnadu, as well as to explore    the breastfeeding problems of them.

Study Design and setting
A Qualitative study design was adopted to reveal the infant breastfeeding experience of women as well as to explore the problems from breastfeeding among them. This study was conducted in the Paediatric ward of Rajah Muthiah Medical College & Hospital (RMMCH), Chidambaram, Cuddalore district, Tamilnadu, India.

Procedure
In this study, 20 women who were currently breastfeeding the infants between October 2016 and December 2016 were selected using a purposive sampling technique. The data collection was carried out by interviewing mothers in their own language using a semi-structured interview schedule. In this interview schedule, the demographic data was collected, and an unstructured questionnaire was used to cover two dimensions such as physical (9 items) and social (5 items) to assess the lived-in experiences of breastfeeding mothers in hospital settings. The informed consent was acquired from all the participants prior to the interview session. After this interview schedule, the audio-taped interview dialogues were listened to and transcribed into verbatim. The collected data were analyzed by using modi ied Colaizzi's seven-step methodological interpretation approach (analysis framework) to retain the mother's viewpoint, which promotes a better understanding of the mother's viewpoint. Colaizzi's Analysis Frame Work includes a) Read all protocol to acquire a feeling of them, b) Review each protocol & extract signi icant statement, c) Spell out the formulated meaning of each signi icant statement, d) Organize the formulated meanings into cluster of themes, e) Integrate results into an exhaustive description, f) Formulate an exhaustive description, g) Ask participants about the inding.

Statistical analysis
Descriptive statistics were applied to analyze the collected data on demographic variables and physical as well as social dimensions. Statistical analysis was done using Statistical Package for the Social Sciences (SPSS) version 23.

RESULTS AND DISCUSSION
Demographic variables were analyzed to describe the characteristics of the study population. The results of the demographic variables are presented in Table 1 . About age, all 20 mothers (100%) belonged to the age of 21-25 years. While reviewing the educational status, seven mothers (35%) were illiterate, 11 (55%) of them had a primary school education, and two mothers (10%) had a high school education. All the selected mothers (100%) were observed as housewives. Moreover, 19 (95%) mothers were Hindu, and only one (55%) was Muslim.
Regarding the type of family, 16 (80%) mothers were from a nuclear family, and 4 (20%) of them were from a joint family. Further, it is revealed that 13 (65%) of mothers belonged to the income group of between Rs.2001-2500 and 7 (35%) of them between Rs.2500 and above. Concerning the mother's age, 14 (70%) mothers were between 20-22 years, and 6 (30%) of them were between 23-25 years.
The number of mothers residing in rural were 15 (75%) and 5 (25%) were from urban areas. While looking into the nature of their diet, all selected mothers (100%) were observed as non-vegetarian. Likewise, all selected mothers (100%) had undergone 3-4 visits of antenatal checkup during pregnancy. Lastly, only one mother (5%) has received previous education about breastfeeding, whereas 95% of mothers (i.e., n=19) did not receive previous education about breastfeeding, which is a critical inding in this study.
Moreover, physical and social dimensions were analyzed to reveal the infant breastfeeding experience of mothers, and the results are described in Tables 2  and 3. All the selected mothers (100%) experienced breastfeeding dif iculties like latching dif iculty, do not know about burping after feeding, and inappropriate positioning while handling the baby. Besides, two mothers (10%) experienced a lack of milk secretion; 6 mothers (30%) experienced pain over the breast while irst sucking of the nipple; 3 mothers (15%) experienced inverted nipple, and six mothers (30%) mothers experienced breast engorgement. Further, it is observed that 11 (55%) mothers experienced headache, which was intermittent in nature, and 13 (65%) mothers experienced fatigue, feeling of tiredness, and unable to sleep. Lastly, 11 (55%) mothers experienced disturbed sleep due to frequent breastfeeding the baby during night time and had redness of the eyes, delay to bed, and less time to sleep.
Also, the results showed that 20 (100%) mothers had adequate family support, especially from their mother in the form of assistance throughout hospitalization, support during breastfeeding, and care of the newborn baby. The relatives also offered social support for all 20 mothers (100%). It is revealed that 20 mothers (100%) did not attend any social gatherings about breastfeeding. Only one mother (5%) has experienced as she had gained knowledge about breastfeeding through the media (i.e., books and advertisements).
This research study aimed to assess the infant breastfeeding experience of women who were admitted to the Pediatric ward of RMMCH, Chidambaram, Cuddalore district, India. The data on demographical variables and physical as well as social dimensions were collected using a semistructured interview schedule. The instrument used to collect the data consists of two sections; Demographic data of mothers and unstructured questionnaire semi-structured interview schedule consisting of questions based on physical and social dimensions.
While reviewing the demographic results, all the selected breastfeeding mothers were aged between 21-25 years, and it is consistent with indings observed by (Hardanahalli et al., 2016) in which more percentage of breastfeeding mothers were observed between 20-30 years. About 55% of breastfeeding mothers had primary school educational status, and 35% were found as illiterate. It is observed that 100% of selected mothers were housewives, and 80% of them lived in a nuclear family, whereas 20% in a joint family. These indings are consistent with the results found by (Motee et al., 2013). They stated that homemakers have unlimited time available to feed their infants.
Conversely, it is found that facility at workplace allow mothers a lexible time to maintain breastfeeding (Amin et al., 2011) and it is also noted that breastfeeding is discontinued before the recommended period by women who are doing professional work in urban areas (Abada et al., 2001). In the case of monthly income, 65% of breastfeeding mothers had Rs.2001-2500 as their monthly income. Furthermore, most of the mothers have their residence in rural areas, and all of them have a mixed nature of the diet. All 20 mothers had 3-4 visits of antenatal checkup during pregnancy. The highpoint of these indings is about 95% of breastfeeding mothers have never been educated previously about breastfeeding, and this inding is associated with previous studies conducted by (Ekambaram et al., 2010;Shwetal et al., 2012).

Physical dimensions
In this study, it is observed that 100% of breastfeeding mothers experienced breastfeeding dif iculties like latching dif iculty and burping problem, and about 10% of mothers experienced lack of milk secretion. A study by (Motee et al., 2013) stated a signi icant number of respondents in their study complained about sore nipples, engorged breasts, back pain and tiredness which is consistent with our indings, as 30% of mothers complained pain and 30% of them experienced breast engorgement. Breast engorgement commonly occurs due to the accumulation of breast milk, while sore nipples result from the baby sucking the nipple area of the breast only (Shams, 2011) These results are in accord with previous studies stating that many women faced dif iculties such as cracked nipples, engorged breasts, and inadequate milk supply (Waldenstrom, 2004;Lamontagne et al., 2008).
Further, three mothers (15%) experienced an inverted nipple, which is described as a reason by mothers for discontinuing breastfeeding. However, an inverted nipple can be treated with proper consultation with doctors (Singh et al., 2016).Out of 20 mothers, 11 (55%) of them experienced intermittent headache; 13 (65%) of them felt fatigued and 11 (55%) mothers experienced disturbed sleep due to frequent breastfeeding the baby during night time and had redness of the eyes. (Waldenstrom, 2004) stated that in general, lactating mothers breastfeed their children often every two hours in the daytime, which results in back pain and tiredness. Those mothers stated that such breastfeeding dif iculties led to a negative breastfeeding experience, which in turn decrease their con idence to wet-nurse their infants, thereby, resulting in early discontinuation of breastfeeding.

Social dimensions
While reviewing the results, it is observed as all the 20 mothers had enough support from family, especially from their mother and relatives during breastfeeding and infant care throughout hospitalization. These indings are consistent with the statement as social support is essential for lactating mothers to make their decision earlier to breastfed and to learn how to breastfeed and regulate the process (Nelson and Sethi, 2005). Even though this study observed as 80% of mothers lived with a nuclear family, they received social support from family members. Furthermore, it is also revealed that 20 mothers (100%) did not attend any social gatherings about breastfeeding, and only one mother (5%) has experienced as she had gained knowledge about breastfeeding through the media (books, advertisements). What about support from doctors and nurses? In this regard, it is essential to overlook the demographic results that 75% of the study population is from rural areas, and about 95% of them had no previous education about breastfeeding. These indings explained the urgent need for social marketing initiatives, such as conducting more campaign or promotional activities to encourage breastfeeding. (Boparai, 2013) also stated that social marketing initiatives such as promotions, advertisements, and imagery in media motivate breastfeeding among mothers and reinforce their perception by demonstrating the breastfeeding as a healthy and conventional practice. A wide range of audience was covered through media campaigns, and public channels such as television, radio, printed materials, or outdoor advertising are commonly used in promoting breastfeeding. Such initiatives should focus on both mothers and their family members who help her during breastfeeding. Likewise, the articles by various women's magazines should also emphasize the bene its of breastfeeding among women.

CONCLUSIONS
This research work was intended to conduct a qualitative study to assess infant breastfeeding experience of women in RMMCH, Cuddalore district, Tamilnadu. According to physical dimensions, breastfeeding dif iculties such as latching dif iculty, lack of milk secretion, burping, inverted nipple, pain, and breast engorgement, intermittent headache, fatigue, and disturbed sleep are revealed among the selected breastfeeding mothers in this study. Concerning social dimensions, all breastfeeding mothers included in this study received social support from family members and their relatives during breastfeeding. However, those mothers have not participated in social gatherings about breastfeeding, and only very few are exposed to social media that encouraging breastfeeding. Besides, most of the selected mothers had no previous education about breastfeeding. Hence, there is a need to take the appropriate measures to educate women about the importance of breastfeeding and also dif iculties following breastfeeding.

Limitations and Recommendations
This study is limited to a small sample size, which can be increased in future studies. It is recommended to study the demographic variables such as type of delivery, parity, place of delivery, sex of baby, breastfeeding initiation within an hour, and exclusive breastfeeding in the future.