Prevalence and determinants of exclusive breastfeeding among urban mothers of Central Kerala

INTRODUCTION

Breastfeeding is the nature’s way of providing all the essential nutrients for the healthy growth and development for an infant in an easily digestible and absorbable form.¹ Introduction of other foods during the first six months not only predisposes infant to infections, but also leads to problem of malnutrition.^2,3 So World Health Organization (WHO) recommends exclusive breastfeeding up to six months of age. Exclusive breastfeeding is defined by WHO as practice of feeding only breast milk and allows the baby to receive vitamins, minerals or medicines, but water, breast milk substitutes, other liquids and solid foods are excluded. The practice of exclusive breast feeding depends on many factors.⁴ A thorough knowledge of these factors is very essential because it identifies areas of improvement for the promotion of exclusive breast feeding.

Kerala is a state with good health indicators.⁵ Although breastfeeding is nearly universal, the practice of exclusive breastfeeding is particularly low in Kerala.⁶ Recent studies indicate that the prevalence of malnutrition as well as infections among infants is on the rise in Central Kerala.^6,7 Low prevalence of exclusive breast feeding may be one of the factors leading to the rise of malnutrition and infections among infants.⁸ Not much data on this is available regarding this especially from central Kerala. It is against this background that the present study attempts to find out the prevalence of exclusive breastfeeding and factors influencing it among mother infant pairs of Ettumanoor block, Kottayam district.

METHODS

A community based cross-sectional study was conducted in Ettumanoor Panchayat, Kottayam district, Kerala after obtaining approval from College Ethics Committee. Ettumanoor Panchayat was the field practice area of Kottayam Medical College Urban Health Center. The study period was one year from January 2012 to January 2013. All mother infant pairs (infants aged 6-12 months along with their mothers) as enlisted in the updated MCH register of KMCH Centre Ettumanoor were included in the study. Preterm infants, infants born in multiple gestation, infants with congenital malformation and infants diagnosed with immunologic problems were excluded from the study. The calculated minimum sample size was 184. The sample size was calculated using stat calc function of Epi Info version 3.5.1. Prevalence of EBF was taken as 22.3 and an absolute precision of 6% was applied.⁹ All mothers were interviewed using pre tested semi structured interview schedule by home visits. Details of the study were explained to each respondent and written consent was obtained to participate in the study. Data was collected regarding the basic sociodemographic details; type and duration of breast feeding given to the child, the time of initiation of breast feeding. Those mothers who are missed at the first contact were interviewed by repeated visits. Exclusive breast feeding was defined as infants who receive only breast milk (including expressed breast milk) and no water or other fluids (juice, non-human milk) or foods for six months, but allows the baby to receive vitamins, minerals or medicines.⁴

Statistical analysis

Data was coded and entered in MS excel and analysed using SPSS version 19.0. The association was determined using chi square test and significance was considered if P value <0.05 at 95% confidence interval.

RESULTS

Out of the total 238 mother infant pairs registered with the KMCH center 18 were excluded. Five were not available even after three repeated visits. A total of 215 mother infant pairs were studied. The mean maternal age was 29.2 (SD 4.34) and mean infant age was 8.87 (SD 2.076). The child sex ratio was 919.6. All the mothers were literate and majority had an education of high school or above (98.6%). Majority (82.4%) belonged to middle class family as per Modified Kuppuswamy scale for socioeconomic classification.¹⁰ All the mothers underwent institutional delivery. Maternal and infant characteristic of study population was summarized in Table 1.

The prevalence of exclusive breastfeeding for six months was 21.9% (Figure 1). The mean duration of exclusive breast feeding was 4.1 months. Maternal education, maternal occupation, advice on exclusive breasting feeding during antenatal visits, problems in initiation of breast feeding and length of breast-feeding session were found to be significantly associated with exclusive breastfeeding. These factors found significant in univariate analysis were subjected to binary logistic regression. Among them maternal education, advice on exclusive breast feeding during antenatal visits, being a working mother and length of breastfeeding session were independently associated with exclusive breast feeding (Table 2). The reasons for “non-exclusive breast feeding” were summarized in Figure 2.

DISCUSSION

The study showed that prevalence of exclusive breast feeding for six months was on the lower side. This was consistent with the findings of DLHS Kerala data which showed a prevalence of 20.9%.⁹ A similar study from Palakkad district, Kerala also showed a prevalence of 17.2%.¹¹ The data from NFHS-4 survey showed a much higher prevalence.¹² Studies from nearby state of Tamil Nadu reported a prevalence of 34%.¹³ Different studies from various other part of India reported a varied prevalence from 34%-61.5%.^14,15

Advice on exclusive breastfeeding during antenatal visits was a found to be a significant factor in the study. One in every three mother (36.8%) who received advice on exclusive breastfeeding practiced it. Since mothers are more receptive during this period more importance should be given in antenatal clinics to emphasize the importance of exclusive breastfeeding.¹⁶ Importance of antenatal advice was found as a significant factor in other studiesalso.^17,18

Our study showed that as the education of the mother increases the practice of exclusive breast feeding also increased. Mother’s who are better educated are more likely to have knowledge of breastfeeding and are able to practice it. About one third (31.2%) of mothers who had an education of graduation and above practiced exclusive breast feeding for six months. Importance of maternal education was pointed out in certain other studies.^19,20

The study revealed that the practice of exclusive breast feeding is less among working mothers. Only 12.2% of working mothers practiced exclusive breast feeding for six months. 6.5% of mothers reported work related problems for stopping exclusive breast feeding. Many other studies also reported that working mother has lower chance for exclusive breastfeeding.^21,22

The study found that exclusive breastfeeding for six months was seen more among those mothers who breastfed their child more than 15 minutes (44.3%) during each session during their initial’s days of breastfeeding. As the length of breastfeeding increases the baby receives the hind milk, which comes later towards the end of the feed. The hind milk satisfies the baby’s hunger. This needs due attention in the background that the major reason (45.8%) quoted by mother for non-compliance to exclusive breastfeeding was insufficient breast milk (Table 1). The baby may not have received the hind milk during short feeds leading the mother to think that the breast milk was not sufficient. A study of from Iran had a similar finding.¹⁷

The major reasons for non-compliance to exclusive breastfeeding were mother’s feeling of insufficient breast milk (45.8%), followed by the misconception of mothers that water can be given during first six months (19.6%) and medical problems (16.1%). Around 10% of mothers did not practiced exclusive breastfeeding because they become pregnant within one year. Hence couples should be counseled regarding family planning and the need for exclusive breast feeding the baby both during antenatal visits and postnatal visits.

CONCLUSION

The prevalence of exclusive breast feeding is much lower compared to the national average of 51%. For a state with improved health indicators this should be urgently addressed to prevent the occurrence of malnutrition and major infections among infants. Antenatal check-up should also focus on this area as mothers are more receptive during that time. Dedicated efforts should be there to promote breastfeeding among working mothers.

ACKNOWLEDGEMENTS

Authors would like to thank the willing assistance and cooperation of all the mothers in the study and the health workers of KMCH, Ettumanoor. The study would not have been possible without their assistance. Authors immensely grateful to Dr. Anupa Lucas for the help and constant encouragements throughout the study.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: The study was approved by the Institutional Ethics Committee

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