ORIGINAL ARTICLE Journal of Nepalgunj Medical College, 2015

Knowledge and Practice Regarding Breastfeeding Among Mothers Attending

Immunization Clinic in Nepalgunj Medical College Teaching Hospital
Janaki P1, Mishra P2, N Thapa3

ABSTRACT
Background: Breastfeeding has been accepted as the most vital intervention for reducing infant mortality and ensuring optimal
growth and development of children. The current study aimed to assess the knowledge and practice regarding breastfeeding among
mothers attending immunization clinic. Methods: A cross sectional study was mothers having children under 1 year of age, who
attended their children for vaccination and for the treatment of other minor illnesses. The purposive sampling technique was used
for selecting the study subjects. Information regarding patients' demographics, knowledge and practice towards breastfeeding were
collected from these mothers on a pre-designed and pretested questionnaire. Results: A total of 208 women with children between
6 months and 12 months were included in the study. Their age ranged between 18 and 37 years with the mean of 24.9±4.1. Overall
mother's breastfeeding knowledge was good among 35% and excellent among 22% of them while it was unsatisfactory among 43%
of the mothers. Breastfeeding in the first 6 months was practiced by 42% of the participated mothers. Only 23% practiced exclusive
breast feeding. Among those who breastfed their babies, 51% initiated breastfeeding in the first hour of birth, 21% between 2-4
hours and only 20% initiated it after 24 hours. Only 73% of mother had not given any prelacteal feeding to their babies. No enough
breast milk (47.9%), crying hungry (31.5%), work-related problems (13.7%) & mothers' illness (6.8%) were the commonly reported
barriers against exclusive breastfeeding. Conclusion: The prevalence of EBF for up to 6 months of age was still low as per WHO
recommendations. The mother's perception of “insufficient breast milk” was also the main reason for introducing other foods.
Optimal breastfeeding promotion campaigns need to be carried out within the existing health care system such as the antenatal,
after delivery and vaccination clinics.

Key words: Breastfeeding, exclusive, prevalence, knowledge, practice

INTRODUCTION an infant5. Poor breastfeeding practices are widespread. It is

Good infant feeding and healthcare are critical for growth and estimated that sub-optimal breastfeeding, especially non-
development of children in the first few years of life1. Optimal exclusive breastfeeding in the first 6 months of life, results in
infant feeding practice recommended by World Health 1.4 million deaths and 10% of the disease burden in children
Organization (WHO) and United Nations Children's Fund younger than 5 years of age6. Reviews of studies from
involves early initiation of breastfeeding within 1 hour of birth; developing countries show that infants who are not breastfed
exclusive breastfeeding for the first 6 months of life; and the are 6 to 10 times more likely to die in the first months of life
introduction of nutritionally-adequate and safe than infants who are breastfed7,8.
complementary (solid) foods at 6 months together with
continued breastfeeding up to 2 years of age or beyond2. The key to successful breastfeeding is Information, Education
and Communication strategies aimed at behavior change. For
Breastfeeding has been accepted as the most vital intervention such a promotional campaign to be effective, attitudes and
for reducing infant mortality and ensuring optimal growth and practices of health providers must be improved9. Exclusive
development of children3. About 800 000 children's lives could breastfeeding stands out as the single most effective
be saved every year among children under 5, if all children 0–23 intervention for child survival10. Universalizing early (within one
months were optimally breastfed4. Breastfeeding is the ideal hour) and exclusive breastfeeding for 6 months, is viewed as a
method suited for the physiological and psychological needs of major public health intervention to reduce the child mortality,
particularly, in the neonates and infants11,12.
1. Mrs. Janaki Parajuli
2. Dr. Pradip Mishra A study done in Australia found that the level of basic breast-
3. Dr. Narbadha Thapa feeding knowledge of Australian midwives was adequate but
there are deficits in key areas. They noted that knowledge
Address for correspondence:
variations by midwives may contribute to conflicting advice
Mrs. Janaki Parajuli
Department of Community Medicine experienced by breast-feeding women13.
Nepalgunj Medical College Teaching Hospital,
Kohalpur, Banke, Nepal Factors that are positively associated with breastfeeding at six
Email: [email protected] months included a very strong desire to breastfeed, having
32 JNGMC Vol. 13 No. 1 July 2015
 Parajuli et al.: Knowledge and Practice Regarding Breastfeeding Among Mothers Attending Immunization Clinic in Nepalgunj Medical College
Teaching Hospital

been breastfed oneself as a baby, and being older. On the other Knowledge on breastfeeding included 38 items, covering the
hand, factors that are negatively associated included a woman following scopes of knowledge on breastfeeding: general
having no intention to breastfeed for six months or more, baby knowledge, colostrum, advantages to mothers and babies,
receiving formula while in hospital, smoking 20 or more effective feeding method, duration of feeding, complementary
cigarettes per day before pregnancy, not attending childbirth feeding, problems with breastfeeding. Each item had
education sessions, and having self-reported anxiety or categorical responses of yes, no, or do not know. A correct
depression which was a problem in the six months after birth14. response will be scored as '1', whereas a wrong or do not know
Interventions that seek to increase breastfeeding should response will be scored as '0'. Total knowledge score ranged
consider focusing on women who are most at risk of early from 0 to 38, with higher scores indicating more knowledge.
discontinuation of breastfeeding. Lack of knowledge, non- Knowledge of mothers whose scores are less than 50% (i.e.,
supportive behaviours and attitudes of maternity nurses, <19) were considered as “unsatisfactory”, 50% to <75% (i.e.,
inconsistent advice, and minimal prenatal encouragement to 19-28) as “good”, while mothers' knowledge scores 75% or
breastfeed have been cited as barriers to breastfeeding15. Some more (i.e., 29-38) were considered as “excellent”. Breast
nurses and physicians are less than supportive of breastfeeding feeding practices were assessed with initiation of
and tend to encourage mothers to supplement with formula or breastfeeding, colostrum feeding, prelacteal feeding and
to give up altogether if they experience difficulties with exclusive breastfeeding upto six months of age or not. Before
breastfeeding16. collecting the information, permission was taken from the
institute authority and verbal consent was taken from the
respondents. The data was entered in SPSS 17 software
Another study noted that, across disciplines, inadequate
package and analyzed.
professional support for breastfeeding has been identified in
the literature. They also stated that: “The adequacy of health
RESULTS
professionals' performance in the promotion of breastfeeding
Baseline characteristics of respondents
has been questioned repeatedly”17. Physicians have significant
A total of 208 women, with children aged between 6 months
educational needs in the area of breastfeeding management18.
and 12 months, attending immunization clinic were included in
Breastfeeding offers numerous health advantages to children,
the study. Their sociodemographic characteristics were
mothers, families, and society. The American Academy of
presented in Table I. Age of the women ranged between 18 and
Pediatrics calls for enthusiastic support and involvement of
37 with the mean of 24.9±4.1. Early marriage was done by
paediatricians in the promotion and practice of breastfeeding.
68.3% of them with 38% teenage pregnancy. 40.9% of the
respondents came from rural area. Only 70% of the
The mean total duration of breastfeeding in Nepal, like most respondents live in their own house. Although 54% of the
other low and middle income countries, is long and usually respondents completed their higher secondary level of
more than two years19, but data on EBF up to six months of age education, 3/4th of them were housewife.
as well as continuous breast feeding practices are scarce.
Information on breastfeeding practices and the factors Table II depicts the children information. Almost 3/4th of the
influencing them is important for successful campaigns. Hence, children were male, 53.4% less than 9 months with 96%
we undertook cross-sectional survey in an immunization clinic hospital delivery.
of tertiary hospital, Kohalpur, Nepal. The current study aimed
to assess the knowledge and practice regarding breastfeeding Breastfeeding Knowledge
among mothers attending immunization clinic. Advice regarding breastfeeding was received by almost 73% of
the women participated in the study. Table 3 shows that
MATERIAL AND METHODS majority of the women (67.3%) were aware of the benefits of
A cross sectional study was carried out in immunization clinic breastfeeding for reducing the frequency of diarrhoea.
which runs once a week on Nepalgunj Medical College However they had unsatisfactory knowledge regarding other
Teaching Hospital, Kohalpur, Banke, Nepal between August benefits to babies. Regarding benefits to mothers majority 87%
2014 to December 2014.The study subjects were mothers were aware that mother who practiced breastfeeding had a
having children aged under 1 year of age, who attended their low risk of getting breast cancer, prevent breast engorgement
children for vaccination and for the treatment of other minor (72%), helps achieving pre-pregnancy weight faster. Only 23%
illnesses. The purposive sampling technique was used for were knowing that exclusive breastfeeding is beneficial in
collecting to select the study subjects. Information regarding spacing birth. It is evident that the knowledge of participated
patients' demographics, knowledge and practice towards mother regarding colostrums in insufficient except its
breastfeeding were collected from these mothers on a pre- definition where 72% of them properly answered that it is the
designed and pretested questionnaire20. mother's early milk which was thick, sticky and yellowish in
colour.
It comprised 3 parts: Sociodemographic characteristics,
knowledge about breast feeding and breast feeding practices.
JNGMC Vol. 13 No. 1 July 2015 33
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Socio demographic Data Frequency Percentage

Age(years) <20 12 5.8
20-30 181 87
>30 15 7.2
Mean± SD 24.9 ± 4.1
Age at marriage (years) <20 142 68.3
>=20 66 31.7
Age at first child <20 79 38
>=20 129 62
Address Rural 85 40.9
Urban 111 53.4
Residence Own house 145 69.7
Rent 63 30.3
Living in joint family Yes 94 45.2
No 114 54.8
Education Illiterate 21 10.1
Primary 17 8.2
Secondary 56 26.9
Higher sec and above 114 54.8
Husband's education Illiterate 2 1
Primary 27 13
Secondary 54 26
Higher sec and above 125 60.1
Occupation Housewife 158 76
Governmental 15 7.2
Private 35 16.8
Husband's occupation Governmental 39 18.8
Private 163 73.6
No work 16 7.7

Table I: Sociodemographic characteristics of respondents (n=208)

Characteristics of data Frequency Percentage

Sex Male 155 74.5
Female 53 25.5
Age in months <9 111 53.4
>=9 97 46.6
Place of delivery Hospital 199 95.7
Home 9 4.3

Table II: Characteristics of children (n=208)

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Statement Correct answer

Benefits to babies n %
1.Breastfeeding reduces the risk of respiratory infection 102 49.04
2. Breastfeeding increases the baby's intelligence 88 42.31
3. Breastfeeding helps to reduce the incidence of child abuse and neglect 95 45.67
4. Baby who received breastfeeding is less prone to get diarrhea 140 67.31
5. Breast milk provides baby with more protection from allergy compared to formula milk 80 38.46
6. Breastfeeding causes good development of baby's teeth and gum 100 48.08
Benefits to mothers
1. Exclusive breastfeeding is beneficial in spacing birth 55 26.44
2. Breastfeeding helps to stimulate uterine contraction 70 33.65
3. Mothers who practiced breastfeeding may achieve pre-pregnancy weight faster 120 57.69
4. Frequent breastfeeding may prevent breast engorgement 150 72.12
5. Mother who practiced breastfeeding has a low risk of getting breast cancer 181 87.02
6. Breastfeeding may protect against osteoporosis 77 37.02
Colostrum
1. Colostrum is the mother's early milk, which is thick, sticky, and yellowish in colour 150 72.12
2. Colostrum is difficult to digest and needs to be discarded 80 38.46
3. Colostrum causes constipation among babies 73 35.10
4. Colostrum is not able to protect babies from jaundice 80 38.46
Effective feeding
1.Baby will gain weight if they receive effective feeding 122 58.65
2. Correct positioning helps to achieve effective feeding 112 53.85
3. Babies sleep well after they receive adequate breastfeeding 190 91.35
Duration of feeding
1.Breastfeeding should be initiated within 30 minutes after deliver 155 74.52
2. Breastfeeding should be on demand 160 76.92
3. Baby should be allowed to breastfeed for at least 10-20 minutes for each feeding 79 37.98
4. Breastfeeding should be continued upto 2 years even though the baby has received 180 86.54
complementary food
Complementary feeding 0.00
1. Complementary feeding should be introduced at 6months of age 180 86.54
2. Mothers may mix breastfeeding and formula feeding once baby starts taking complementary 190 91.35
food
Problems
1. Breast milk production is influenced by breast size 112 53.85
2. Mothers will inverted nipples cannot breastfeed their babies 130 62.50
3. Breastfeeding must be discontinued if mother has cracked nipple 101 48.56
4. Breastfeeding must be discontinued if baby has jaundice 110 52.88
5. Breastfeeding must be discontinued if mother has breast engorgement 80 38.46
6. Breast engorgement may be reduced with cold packs 120 57.69
Practical aspects 0.00
1. Exclusive breastfeeding must be practices until infant is 6 months old 190 91.35
2. Massage may reduce breast engorgement 100 48.08
3. Giving water to baby is encouraged after every breastfeeding 120 57.69
4. Belching after feeding shows that the baby is full 190 91.35
5.Babies who get enough feeding will pass urine more frequently 112 53.85
6. Oral thrush frequently happens to babies who breastfeed 95 45.67

Table III: Knowledge regarding breastfeeding among participants (n=208)

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In addition, table III shows that knowledge of mothers

regarding effective breastfeeding is excellent (91%) regarding 22%
babies sleeps well after receiving adequate breastfeeding. 43%
Their knowledge is sufficient regarding duration of
breastfeeding (ranging from 74.5% to 84.5%) except for the fact
that baby should be allowed to breastfeed for at least 10-20 Unsatisfactory
minutes for each feeding. Their knowledge regarding Good
complementary feeding was sufficient as 91.4% regognized
that they may mix breastfeeding and formula feeding once Excellent
baby starts taking complementary food while 86.5% were
aware that complementary feeding should be introduced at 6
months of age.
35%
It is evident from table 3 that the mothers' knowledge
regarding problems with breastfeeding is insufficient. For
example, only 39% answered that breastfeeding must be Figure 1: Level of knowledge regarding breastfeeding
continued if mother has breast engorgement, 48.5% answered
that breastfeeding must be continued if the mother has cracked
nipple and 53.9% answered that breast milk production is not
influenced by breast size.

As shown in table 3, the knowledge of mothers regarding

practical aspects of breastfeeding is sufficient in some of them 20%
as exclusive breastfeeding must be practiced until the infant
was 6 months old and blenching after feeding showed baby was Within 1 hour
full (91%), while it was insufficient in other aspects as false 9%
beliefs like giving water to baby is encouraged after every 2 - 4 hours
breastfeeding (54%), oral thrush was frequent in babies who
breastfeed was (46%), massage may reduce breast
5 - 24 hours
engorgement (48%).
after 24 hours
Figure 1 demonstrates that overall mother’s breastfeeding
knowledge was good among 35% and excellent among 22% of 51%
them while it was unsatisfactory among 43% of the mothers. 21%

Practices regarding breastfeeding

Breastfeeding in the first 6 months was practiced by 42% of the Figure 2: Initiation of breast milk
participated mothers. Only 23% practiced exclusive breast
feeding. Among those who breastfed their babies, 51%
initiated breastfeeding in the first hour of birth, 21% between
2-4 hours and only 20% initiated it after 24 hours. Only 73% of
mother had not given any prelacteal feeding to their babies.
21%
Barriers to Exclusive Breast Feeding
As obvious from figure 4, no enough breast milk (47.9%), crying
6% None
hungry (31.5%), work-related problems (13.7%), mother illness
(6.8%) were the commonly reported barriers against exclusive
Glucose water
breastfeeding.
Formula milk

73%

Figure 3: Use of prelacteal feeding

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60 WHO2. But it should also be considered that prevalence of EBF

47.95 will also depend upon the methods of data collection and
50 definitions used in the study.
40
31.5 Preparation of mothers before they give birth is fundamental to
30 the success of exclusive breastfeeding. However in our study it
was seen that only 59% of the women had received any advice
20 13.7 on breastfeeding during antenatal period. Similar study done in
Pokhara showed only 53% of the women received advice on
10 6.8
breastfeeding during ANC visits29. In India advice were received
only by 48% of women30. Support and counseling should be
0 available routinely during ante-natal care, to prepare mothers;
Crying/ Mother no enough work at the time of birth to help them initiate breastfeeding; and in
Hungary Illness breast milk related the postnatal period to ensure that breastfeeding is fully
established.
Figure 4: Barriers against exclusive breastfeeding
Regarding initiation of breastfeeding 74.5% of mothers had
DISCUSSION idea on starting breast feeding within ½-1 hr of birth (table III)
Exclusive breastfeeding for the first 6 months of life improves and in practice only 51% mothers started breast feeding within
the growth, health and survival status of newborns21 and is one ½-1hr of birth. Data from 2006 NDHS showed that nearly 1 in 3
of the most natural and best forms of preventive medicine22. children were breast-fed within ½-1hr19. One study done in
Exclusive breastfeeding plays a pivotal role in determining the Dharan showed only 10 % of the mother had knowledge
optimal health and development of infants, and is associated regarding initiation of breastfeeding but 41.5% practice it31.
with a decreased risk for many early-life diseases and According to a study conducted in rural Ghana, it was
conditions, including otitis media, respiratory tract infection, concluded that if all women initiated breastfeeding within 1
diarrhea and early childhood obesity23. hour of birth, 22% of the infants would be saved from death. In
the Indian context, this means that 250,000 nenates can be
Currently the recommendations from the global strategy for saved from death annually by just one act of initiation of
infant and young child feeding, developed by the World Health breastfeeding within 1 hour of birth32. In one study done in
Organization and UNICEF, is that infants should be exclusively India, it was seen that although 92% of the mothers knew the
breastfed for the first 6 months of life22. Still, less than 40% of recommendation of initiating breastfeeding within one hour
infants under 6 months of age in the developing world are only 36% had actually done it30.
exclusively breastfed24.
One of the major reasons for the delay in our study was that the
Despite UNICEF and WHO recommendations, only 53% of child was sick. This could be because of the fact that the study
children under 6 months of age were exclusively breastfed in was conducted in a tertiary care institute where mothers
Nepal. Median duration of any breastfeeding is about 34 whose babies were sick were retained in the hospital for more
months and exclusive breastfeeding were about 4.2 months25. days and were included in the study. The second reason was
Thought 91 % had good knowledge regarding EBF, rate of EBF that there was delay in shifting from labour room. The other
practice up to six months of age in our study (23%) was reasons (too tired to sit up and feed, baby was sleeping) only
substantially lower than the 53% finding in the National reflected that the mothers were not motivated adequately for
Demographic Health Survey (NDHS) in 200619. Poverty and initiating breastfeeding within one hour of birth. Hence
ignorance were the main reasons for this practice, which is one intensive efforts need to be put for the timely initiation of
of the major causes of malnutrition among infants25. In a study breastfeeding preferably within the labour room itself if there is
by Chudasma RK et al in Rajkot also showed the prevalence of delay in shifting and the importance of early initiation of
exclusive breast feeding at 6 months of age of infants was found breastfeeding needs to be stressed to the mothers in the
to be 62%(26). antenatal period itself.

Foo LL et al reported prevalence rate of 21% which is similar The unique nutritional and antibody properties of colostrum
compared to present study27. Whereas the study done by and the disadvantages to those infants not fed with colostrum
Yadavannavar MC and Shailaja S Patil showed only 13.36% of are now well recognized and documented2. In our study, only
mothers practiced almost exclusive breast feeding up to 4 38% of the mothers knew that colostrum needs to be given
months28. This shows despite the demonstrated benefits of which is very low compared to others studies in India where the
breast feeding, breast feeding prevalence and duration in many importance of colostrum was known to 75- 90% of the
countries exclusive breast feeding for the first 6 months of life mothers33,34.
are still lower than the International recommendations of
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The mother's perception of “no enough breast milk” is a well- Pacific. South Asia report. Feb 2007.
known problem hindering optimal EBF practice in many 4. Black RE, Victora CG, Walker SP, and the Maternal and Child
communities35,36. A key reason, however, why a child could Nutrition Study Group. Maternal and child undernutrition and
remain hungry is not because breast milk is insufficient but overweight in low-income and middle-income countries. Lancet
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