Insights into the Knowledge, Attitude, and Practices of Mothers with Infants under 6 Months at a Tertiary Care Center in Southern Tamil Nadu

INTRODUCTION

Breastmilk is said to be the ideal food for infants. It is both safe and clean. It also protects against infections as it contains antibodies. Breast milk alone can provide all the nutrients and energy required for the first 6 months, half of the requirements for the second 6 months, and up to one- third of the requirements for the 2^nd year of life. Intelligence tests had reported that breast-fed infants fared better than the other infants.

Breastfed infants were also less likely to develop obesity and diabetes mellitus in the future. The probability of breast and ovarian cancers is reduced in breast-fed women.^[1] The World Health Organization (WHO) and the United Nations Children’s Fund (UNICEF) recommend initiation of breastfeeding within the 1^st h after birth, exclusively breastfeeding for the first 6 months of age, and continuation of breastfeeding for up to 2 years of age or beyond, in addition to adequate complementary food.^[2,3] For the above to be accomplished, knowledge about breastfeeding is very vital. For the knowledge to culminate in practice, a positive attitude toward breastfeeding is also important.

The present study was conducted to analyze and ascertain the knowledge, attitude, and practice of breastfeeding among lactating mothers. Similar studies have not been conducted in this setting before. The study will shed light on the domain of knowledge about breastfeeding in which the mothers are lacking and also give an idea about the present pattern of breast-feeding practices in the study setting. The study will also try to find the attitudes of mothers toward breastfeeding. All of the above will aid in creating a tailor-made health education campaign for breastfeeding mothers in the study setting.

MATERIAL AND METHODS

The present study was a cross-sectional study carried out in the pediatrics department of Sivagangai Medical College, Tamil Nadu. The study was carried out for a period of 3 months between January 2024 and March 2024 among the mothers of infants (0–6 months). Ethical clearance for the study was obtained from the Institutional Ethics Committee. Informed consent was obtained from all the mothers included in the study.

The sample size was fixed at 500, and a convenient sampling technique was used. All the mothers with infants aged 0–6 months who had attended the outpatient department (OPD), immunization OPD, and were admitted to the postnatal wards during the study period were approached for participation in the study.

Lactating mothers with chronic illnesses such as cancer, hepatitis B, hepatitis C, human immunodeficiency virus/acquired immunodeficiency syndrome, or on anti retroviral therapy (ART) or antipsychotic drugs; mothers on top-up formula feeds or cow’s milk; babies with cleft lip or palate; Down’s syndrome; congenital heart disease; or any major congenital anomalies; mothers with preterm babies or twin babies; and babies admitted to the neonatal intensive care unit were excluded from the study. Those who were not willing to participate were also excluded from the study.

The data for the study were collected using a pretested, structured questionnaire. The questions included the general information, including the age of the mothers collected as completed age, educational qualification collected as either illiterate, studied up to high school, graduate or postgraduate, occupation of the mother collected as homemaker or employed, and the type of family recorded as nuclear or joint. The information regarding the receipt of antenatal care was sought and recorded as yes or no. The mode of delivery was recorded as either vaginal delivery or cesarean section. The information about whether counseling for breastfeeding was provided in the antenatal period or not was recorded.

The knowledge domain consisted of ten questions, and all the questions were of multiple-choice types. The correct answer, if provided, was scored with a one, and the wrong answer was a zero. The attitude domain also consisted of ten questions with options for agree, unsure, and disagree. The practice part also consisted of ten questions, and all the questions here were also of the multiple-choice type.

The collected data were entered into Microsoft Excel 2019, and a master chart was created. The master chart was then loaded onto the Statistical Package for the Social Sciences version 26 for statistical analysis. The qualitative data were expressed using frequency and percentage, and the quantitative data were expressed using mean and standard deviation. Pie charts and bar diagrams were used to represent the results pictographically.

RESULTS

Among the 500 participants, 281 (56.2%) mothers were of age 19–25 years, followed by 160 mothers (32%) of age 26–30 years. Two hundred and thirty-three mothers (46.6%) had studied up to high school, followed by 164 mothers (32.8%) who were graduates. Three hundred and eighty-five mothers (77%) were homemakers, and 265 mothers (53%) belonged to nuclear families. Four hundred and seventy-eight mothers (95.6%) reported to have received antenatal care, and for 265 mothers (53%), the annual family income was 1 lakh to 2 lakh rupees. Three hundred and nine mothers (61.8%) had only one child, followed by 149 mothers (29.8%) who had two children. The last delivery was vaginal in 324 mothers (64.8%) and cesarean in 176 mothers (35.2%). One hundred and eighty-eight mothers (37.6%) reported to have received counseling about breastfeeding during the antenatal period [Table 1].

Table 1: Sociodemographic characteristics of participants.

About 463 mothers (92.6%) reported that exclusive breastfeeding (EBF) is important. Three hundred and ninety-seven mothers (79.4%) reported colostrum to be immunologically beneficial to the child. Four hundred and fifty-nine mothers (91.8%) answered that EBF improves immunity. Four hundred and eight mothers (81.6%) were aware that breastfeeding should be initiated within 1 h after birth. Four hundred and thirty-one mothers (86.2%) were aware of the fact that breastfeeding prevents infections such as diarrhea and pneumonia in children. Three hundred and fifty-four mothers (70.8%) stated EBF to be done for 6 months. Two hundred and eighty-nine mothers (57.8%) only knew that breast milk could be expressed and stored. Two hundred and forty-four mothers (48.8%) reported that one can assess the adequacy of breastfeeding when the baby passes urine more than 5 times a day. Three hundred and eighty-one mothers (76.2%) had known that frequent suckling improved milk production. Three hundred and ninety-one mothers (78.2%) knew that the weight gain pattern of a breastfed infant would vary from that of a formula-fed infant [Table 2].

Table 2: Distribution according to answer to knowledge-based questions.

Three hundred and twelve mothers (62.4%) agreed that breastfeeding can be continued up to 2 years of age, and 160 mothers (32%) were unsure about it. Two hundred and ninety-five mothers (59%) were positive about providing breastmilk on demand, and only 34 mothers (6.8%) disagreed. Two hundred and seventy-two mothers (54.5%) agreed that pre-lacteal feed should never be given to the baby, while 110 mothers (22%) were of the opinion that it should be given. Four hundred and three mothers (80.6%) were positive about following the vaccination schedule. One hundred and seventy-eight mothers (35.6%) had a positive attitude toward breastfeeding the child when the child was having a diarrheal episode, and 133 mothers (26.6%) disagreed with the statement. Three hundred and one mothers (60.2%) believed breastfeeding to be better than formula feeding, while 50 mothers (10%) disagreed with the fact. Three hundred and thirty-nine mothers (67.8%) were of the opinion that health and hygiene are important for breastfeeding, and 139 mothers (27.8%) disagreed about it. Two hundred and fourteen mothers (42.8%) agreed that breastfeeding does not cause any change in body shape, while 139 mothers (27.8%) were of the opinion that it causes some changes. Four hundred and twenty-two mothers (82.2%) positively agreed that breastfeeding increases mother-child bonding. Four hundred and eighteen mothers (83.6%) reported breastfeeding to be continued when the baby is ill [Table 3].

Table 3: Distribution according to answer to attitude-based questions.

One hundred and sixty-five mothers (33%) reported having taken advice from the lactation counselor or medical advisor regarding lactation. One hundred and twenty-four mothers (24.8%) had provided pre-lacteal feeds to the infants. Four hundred and five mothers (81%) gave only breast milk as the first feed to the child. Three hundred and eleven mothers (62.2%) were reported to have initiated breastfeeding within 1 h of delivery, and 51 mothers (10.2%) initiated only after 24 h. Two hundred and ninety-six mothers (49.6%) reported having breastfed the baby on demand. Two hundred and forty-eight mothers (49.6%) reported that they emptied one breast before using the other. One hundred and forty-eight mothers (29.6%) followed dietary restrictions while breastfeeding their children. Four hundred and three mothers (82.6%) reported to have used galactagogues. Fenugreek (33.4%) was the most commonly used galactagogue, followed by garlic (22.8%). One hundred and seventeen (23.4%) reported to have drunk water <2 L per day, and 298 (59.6%) reported to have drunk 2–3 L. Four hundred and forty-one mothers (88.2%) were reported to have followed proper latching and attachment [Table 4 and Figure 1].

Table 4: Distribution according to answers to practice-based questions.

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Figure 1:

Bar chart showing distribution according to the type of galactagogue used.

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DISCUSSION

The WHO and the UNICEF recommend initiation of breastfeeding within the 1^st h after birth, exclusively breastfeeding for the first 6 months of age, and continuation of breastfeeding for up to 2 years of age or beyond, in addition to adequate complementary foods.^[2,3] The present study was conducted to analyze and ascertain the knowledge, attitude, and practice of breastfeeding among lactating mothers.

The present study was a cross-sectional study carried out in the pediatrics department of Sivagangai Medical College, Tamil Nadu, for 3 months. All the mothers with infants aged 0–6 months who had attended the OPD, immunization OPD, and were admitted to the postnatal wards during the study period were approached for participation in the study.

Ethical clearance was obtained from the Institutional Ethics Committee, and informed consent was obtained from all the participants included in the study.

In the present study, almost nine in ten respondents said that exclusive breastfeeding is important. In a study by Newby et al., 85% reported breast milk as the appropriate food for infants, which was similar to the present study.^[4] In the present study, the participants had adequate knowledge in most of the domains of breastfeeding. Suarez Cotelo et al. reported that knowledge regarding breastfeeding is vital as it can influence both the intention and type of feeding of the newborn.^[5] Basrowi et al. reported that mothers have good knowledge regarding breastfeeding.^[6] Altamimi et al. reported satisfactory knowledge among lactating mothers regarding breastfeeding.^[7] Khasawneh et al.^[8] reported that 78% of their participants had good knowledge about breastfeeding.^[9] Abdulahi et al. reported that half of their participants had adequate knowledge about breastfeeding.^[10] Yakubu et al. reported that many mothers have good knowledge about breastfeeding.^[11]

Many mothers lacked the knowledge that breast milk could be expressed and stored. Addressing this knowledge will be very important, as many working women will find it difficult to breastfeed when they resume working.^[7] Usually, the babies have to rely on formula feeds. To overcome it, all mothers should be taught how to express and store breast milk.

In the present study, most women had a positive attitude toward breastfeeding and its practices. Balogun et al. reported that more than two-thirds of the women had a positive attitude toward EBF in their study.^[12] Yakubu et al.^[11] reported the thought that alteration of breast figure following breastfeeding was one of the barriers to breastfeeding. One of the important barriers to breastfeeding could be the attitude of the mother toward breastfeeding. A study reported that mothers feel EBF to be more hard work than formula feeding.^[12] Altamimi et al. reported mothers have a good attitude toward breastfeeding.^[7] Khasawneh et al. reported that 72% of their participants had a positive attitude toward breastfeeding.^[8] Yakubu et al. also reported a positive attitude toward breastfeeding among the mothers.^[11]

One of the pitfalls with regard to practice in the present study was that only a few consulted lactation consultants or medical advisors regarding lactation. In a study by Sabo et al., more than half reported having given pre-lacteal feeds to the baby.^[13] The proportion was lower in the present study, as only about 20% reported having received pre-lacteal feeds. Most women had provided breast milk as the first food to the child. Sabo et al. reported that among the participants, 60% had started breastfeeding immediately after delivery.^[13] A similar proportion was also documented by Yakubu et al.^[11] In the present study, a similar proportion reported having initiated breastfeeding within 1 h of birth. Omar et al. reported cesarean sections as a barrier to the early initiation of breastfeeding.^[9] Almost eight in ten participants reported having consumed galactagogues in one form or another. The self-reported water consumption per day was also on the lower side among the study participants.

The strengths of the study were that it explored the knowledge, attitude, and practice among the mothers who are practicing breastfeeding at present, and the recall bias will be lessened as the events of the study have taken place just now. The limitations were that the results had to be generalized with caution. A multicenter study with the same objective will provide a more generalizable result.

CONCLUSION

Many participants were found to have adequate knowledge, positive attitudes, and good practice toward breastfeeding. The knowledge regarding expressing and storing of breastmilk is on the lower side. The proportion who had consulted a lactation consultant/medical advisor regarding lactation was also lesser, and so was the self-reported water consumption among the lactating mothers. This study helps us to assess the breastfeeding rate at the rural level and helps to counsel them regarding the importance of breastfeeding and advise them about methods of breastfeeding, storage of breast milk, and methods to increase milk production and proper ways of attachment, thereby increasing the breastfeeding rate in the population.