Knowledge, attitude and practice of Breastfeeding among lactating mothers in a tertiary care hospital

Knowledge of Breastfeeding and its practice among lactating mothers is an essential factor which determines the breastfeeding rates. Exclusive breastfeeding helps in preventing neonatal and infant mortality and morbidity and is one of the most important public health intervention, which can reduce the under-five mortality also. This study was conducted in Saveetha medical college hospital between March 2020 and June 2020. To assess the knowledge, attitude, Practice of Breastfeeding among lactating mothers. Descriptive cross-sectional study. 100 lactating mothers admitted to our hospital after delivery were selected randomly. They were interviewed based on a questionnaire which was prepared to assess the knowledge attitude and practice of breastfeeding. Informed consent was obtained after explaining the objective of the study. Out of 100 mothers, 71.38% had good knowledge, 66.6% showed a positive attitude towards breastfeeding, and 63.33% had acceptable breastfeeding practices. The breastfeeding practices followed in our hospital can be improved further by proper counselling and nutritional education of the mothers in the antenatal and immediate postnatal period. The comprehensive lactation management programme which has recently been started in our hospital could aid in the same. Dedicated lactation counsellor and lactation nurse could also help achieve improved breastfeeding practices and attitude towards breastfeeding.

KAP questionnaire, Breastfeeding, Lactating mothers A Knowledge of Breastfeeding and its practice among lactating mothers is an essential factor which determines the breastfeeding rates. Exclusive breastfeeding helps in preventing neonatal and infant mortality and morbidity and is one of the most important public health intervention, which can reduce the under-ive mortality also. This study was conducted in Saveetha medical college hospital between March 2020 and June 2020. To assess the knowledge, attitude, Practice of Breastfeeding among lactating mothers. Descriptive cross-sectional study. 100 lactating mothers admitted to our hospital after delivery were selected randomly. They were interviewed based on a questionnaire which was prepared to assess the knowledge attitude and practice of breastfeeding. Informed consent was obtained after explaining the objective of the study. Out of 100 mothers, 71.38% had good knowledge, 66.6% showed a positive attitude towards breastfeeding, and 63.33% had acceptable breastfeeding practices. The breastfeeding practices followed in our hospital can be improved further by proper counselling and nutritional education of the mothers in the antenatal and immediate postnatal period. The comprehensive lactation management programme which has recently been started in our hospital could aid in the same. Dedicated lactation counsellor and lactation nurse could also help achieve improved breastfeeding practices and attitude towards breastfeeding.

INTRODUCTION
Breastfeeding is the ideal nutrition for neonates. It is the irst fundamental right of any child. Breast milk contains all nutrients for normal growth and development of a baby from the time of birth to the irst six months of life. Breastfeeding is the best gift that a mother can give to her baby. Children who are breastfed have better neurodevelopment outcomes, and the duration of breastfeeding plays a vital role in the IQ of the child (IBFAN, 2005). According to previous studies, increasing the duration of breastfeeding was associated with signi icant increases in both verbal IQ and performance IQ of the child. Early initiation of breastfeeding and correct breastfeeding practices can reduce neonatal and infant mortality and also ensures optimal growth and development (Kumar et al., 2015).
World health organization and UNICEF have laid down some recommendation on IYCF (Infant and young child feeding) practices which includes early initiation of breastfeeding within 1 hour of birth and exclusive breastfeeding for the irst six months of life, the introduction of nutritionally-adequate and safe complementary (solid) foods at six months together with continued breastfeeding up to 2 years of age or beyond.
Longer durations of breastfeeding also contribute to the health and well-being of mothers as it has been found to reduce the risk of ovarian and breast cancer and helps spacing future pregnancies (World Health Organization, 2020). Adequate breastfeeding during early life and adequate energy intake throughout life helps women during lactation and another high demand period without any de iciencies.
Proper knowledge about breastfeeding leads to improvement in attitude and better breastfeeding practices.
Social culture, ignorance, poor knowledge, negative attitudes towards breastfeeding in luences breastfeeding behaviour of lactating mothers. By assessing the knowledge, attitude and practices of Breastfeeding among lactating mothers, we can obtain clear view about the modi ications that need to be done so those speci ic intervention strategies can be made to correct the same.

METHODOLOGY
This study was carried out in lactating mothers who visit or admitted in Saveetha medical college and hospital. The data was collected between March 2020 to June 2020. After explaining the objective of the study to lactating mothers, voluntary participation was encouraged and informed written consent was obtained (Macías and Glasauer, 2014). Through the interview, data were collected by asking questions in their mother tongue. The time taken for each patient was about 10-15 minutes.

Type of the study
Descriptive cross-sectional study.

Data were collected using two questionnaires
The irst questionnaire included demographic details, family income, and type of family, educational status, parity and lactation period.
The second questionnaire was the KAP questionnaire; this included questions to assess knowledge, attitude and practice of breastfeeding. The questionnaire was adapted from previously done research (Krishnendu and Devaki, 2017), which was based on the Food and Agriculture Organization of the United Nations (FAO) guidelines for assessing nutrition related knowledge, attitude and practice. The irst part of the KAP questionnaire contained eight questions to assess the knowledge about breastfeeding. The score for knowledge was based on the number of correct answers selected by the mother. The questionnaire included knowledge about initiation and duration of breastfeeding, the importance of colostrum and exclusive breastfeeding. The second part of this questionnaire contained nine questions to evaluate the attitude of a mother towards breastfeeding and to ind positive and negative attitude towards breastfeeding. This part included a 3 point Likert scale with options like disagreeing, agree, unsure. The last part of the questionnaire had ive questions such as prelacteal feeds, duration of feed, nutritional practices by mother for milk production, etc. to assess breastfeeding practices of a lactating mother.

Inclusion criteria
Mothers who lactate infants aged 0-6 months, admitted in a hospital without any acute or chronic illness were included for this study.

Exclusion criteria
Lactating mothers with a chronic illness like Hepatitis, cancers, HIV were not included for this study.

Data Analysis
Data collected were entered into Microsoft Excel and analyzed. Data were analyzed using statistics comprising of percentage and frequencies.

Demographic and Antenatal details
A total of 100 mothers were included in the study. Of the 100 mothers included in the study, the majority of them were in the age group between 21 to 26 years(54%). Majority of the mothers had school education and had completed 12th standards(60%), but graduates were found to be less than 30% [ Table 1]. More than half of the mothers were from the nuclear family and were homemakers and not working mothers. Monthly income of most of their family was between 8000 Rs to 15000 Rs. More than 50% of mothers were primigravida and had antenatal visits around 4 -6 times.

Knowledge about Breastfeeding among lactating mothers
Majority of lactating mothers selected that exclusive breastfeeding important (94%). Around 84% known about the nutritional bene its of colostrum. 29% of the mothers don't know that immunity of child can be improved by breastfeeding. 91% of the mothers know the importance of breastfeeding within 1 hour after birth. But only 49% of mothers accepted the fact that exclusive breastfeeding can prevent the child from diarrhoea. Less than 50% of mothers only knew that growth pattern differs for breastfed infants from formula-fed infants.
Around 74% of mothers had the knowledge that fenugreeks and almonds ha positive effect on milk production. 64% of the mothers knew exact duration for breastfeeding, 38% did not give importance for proper introduction of complementary feeds and only 8% selected < 6 months as a duration for exclusive Breastfeeding [ Table 2].

Attitude about Breastfeeding among lactating mothers
Around 66 % of the lactating mothers around agreed that breastfeeding should be continued up to 2 years. 62% of mothers gave breastfeeding on demand.51% of mothers disagreed to the belief of giving prelacteal feeds to babies. Around 98% of mothers showed a positive attitude towards vaccination schedule. Regarding breastfeeding during diarrhoea majority of the mothers were either unsure or didn't know whether to continue breastfeeding or not. Similarly, 42% of mothers were unsure about the bene its of breastfeeding in comparison to formula feeds. 95% agreed that healthy and hygienic practices improve breastfeeding. In the same way, around 93% of mothers agreed that breastfeeding betters mother-child relationship and bonding [ Table 3].

Breastfeeding Practices by mothers
All 100 mothers interviewed were lactating, but about 79% of mothers didn't go for any counselling before initiating breastfeeding. Out of 3% of mothers who gave prelacteal feeds, 1% of mothers gave honey as prelacteal feed, and 2% of mothers gave sugar water as prelacteal feed [ Table 4]. Close to 70% of mothers gave breastfeeding within 1 hour of delivery. 61% of mothers gave breastfeeding on demand, and 33% at speci ic intervals. 35% of mothers took galactagogues daily; 39% of mothers took galactagogues randomly [ Figure 1].
Out of 100 mothers, 71.38% had good knowledge ( average of the number of lactating mothers responded correctly for eight questions), 66.6% showed a positive attitude towards breastfeeding ( average of the number of lactating mothers having a positive attitude for nine questions ), 63.33% had acceptable breastfeeding practices ( average of the number of lactating mothers having acceptable breastfeeding practices for six questions ) [Figure 2].

DISCUSSION
Many organizations like Breastfeeding Promotion Network in India (BPNI) (BPNI, 2008) and programmes like Mother's Absolute Affection (MAA) (Mother's Absolute Affection, 2016) have taken many steps to improve breastfeeding practice in India and thereby reduce the infant mortality in our country. This is aimed at achieving the Millennium Development Goal 4, which is reducing the under-ive mortality rate by 2/3 rd (World Health Organization, 2015). But the bene its obtained from those efforts have not still resulted in the desired outcome.
Tamil Nadu stands at 20th place (33.3%) in a report by the BPNI on exclusive breastfeeding and in the same report only 58.8% mothers in our state initiate breastfeeding within one hour (BPNI, 2008). Hence this study of assessing Knowledge Attitude and Practice of breastfeeding among lactating mothers was done to identify the gaps which could be corrected to achieve our goal of attaining exclusive breastfeeding and subsequently reducing the mortality in infants and under-ive children. In our report of early initiation of breastfeeding within one hour was practised by 69 % of the mothers this is similar to the previous study by Ketbi et al. (2018) where there were 72.6% starting breastfeeds within one hour [ Table 4]. However, this inding is in contrast to several studies from other parts of India. This could be probably explained by the fact that we have a lactation management unit in our hospital and mothers get motivated by the lactation nurse.
Similarly continued breastfeeding was reported beyond six months in 92%of the mothers in our study [ Table 2]. which is an indication of good compliance to breastfeeding which again is explained by the good follow up services that are provided in our unit. This is in contrast to data from other studies which have reported exclusive breastfeeding rates up to and beyond six months between 16.9 % to 49.8%.
Majority of the mothers in our study knew that exclusive breastfeeding is important(94%), which is again contrast to the previous studies, 71% of mothers knew its bene it on immunity also. However, less than half of the mothers interviewed (49%) knew Similarly, mothers in our study also showed a positive attitude towards immunization. Almost all the mothers knew about vaccination (98%) [ Table 3] and were eager about the subsequent vaccination, which must be given to the child.
This probably is because of the extensive efforts taken by the Government in promoting vaccination and creating awareness about the bene its of the vaccine.
Mothers interviewed in our study also showed a positive response towards hygienic practices, hand washing and moth child bonding. More than 90 %of the mothers showed a positive response to these aspects.
Mothers in our study were about unsure breastfeeding during diarrheal illness, use of formula as an alternative to breastfeeding. These may be due to the rural background of the mothers and their cultural habits, misguidance by older people, etc.
This could also be a reason for prelacteal feeds like honey, sugar water given to 3 of the babies [ Table 4] included in our study.
Around 80% of mother didn't take any lactation counselling course but were given some form of advice during the antenatal visits. 74% of mothers have knowledge and importance about galactagogues; however, only 35% consumed galactagogues daily, and 39% consumed randomly. These indings are similar to other studies.

CONCLUSION
Many mothers have basic knowledge, but they are unaware about the importance of breastfeeding and breast milk in preventing diarrhoea, improving immunity, prelacteal feeds and are unsure about what to do during diarrhoea etc., this can be improved by better counselling and monitoring by healthcare workers and also by improving maternal knowledge, women education level, use of mass media in promoting breastfeeding activities and antenatal counselling of the mothers. In certain conditions mother knew the bene it still are not practising because of the in luence by an older person, cultural behaviours and work-related stress of the mother lethargic. To improve such situations, health workers are advised to educate and counsel both mother and her family members.

Financial support and sponsorship
The authors declare that they have no funding support for this study.