Knowledge attitude and practice of breast feeding among women who delivered during COVID-19 pandemic in Kollam District, Kerala

INTRODUCTION

Breastfeeding is the top way to provide infants with the nutrients they require. WHO recommends exclusive breastfeeding which starts within one hour after birth till the baby is six months old. Nutritious complementary foods should then be added while continuing breastfeeding for up to two years or beyond.¹

Breastfeeding is the ideal feeding practice for infants which is promoted worldwide by health professionals. Both infants and mothers are benefited from breastfeeding. However, the prevalence of breastfeeding has remained low worldwide. This study was designed to describe the knowledge attitude and practice of breastfeeding among mothers and to assess whether the COVID-19 pandemic has affected breastfeeding practices. This study is designed to describe the knowledge attitude and practice of breastfeeding among mothers and to assess whether the COVID-19 pandemic has affected breastfeeding practices.²

Kerala is a state with good health indicators. Although breastfeeding is nearly universal, the practice of exclusive breastfeeding is particularly low in Kerala.³ The low prevalence of exclusive breastfeeding may be one of the factors leading to the rise of malnutrition and infection among infants.^4-7

Three basic strategies that can bring about a favorable change in the behavior of mothers towards feeding habits are information, education, and communication. Maternal knowledge and comfort predict the feeding practices that they will be following.⁸ In India, the main source of information for mothers remains their own family and friends, and a structured counseling service on child feeding is lacking. The nutritional status of children will be better by promoting feeding practices.⁹

Infant and young child feeding practices will directly affect the nutritional status of children under two years of age and ultimately influence the survival rates of children. Globally, more than nine million children under the age of five die every year. The promotion of breastfeeding knowledge leads to the promotion of attitude and subsequently to the improvement of their breastfeeding practices. Adequate energy intake and a diversified diet throughout the life cycle help ensure that women enter lactation without deficiencies and obtain adequate nutrients during high demand. Knowledge, ignorance, undesirable socio-cultural beliefs, and misconceptions prevailing in the community are reported to influence the breastfeeding behavior of lactating mothers. Very few women in India have the right knowledge about breastfeeding practices.¹⁰

The knowledge and awareness about the techniques of breastfeeding such as the time of initiation of feeding, latching on, mothers’ position while feeding the baby, seems limited. Most of the women may encounter these problems related to improper techniques in the immediate postpartum period. The ideal time to educate them would be the antenatal period itself. However, in the busy antenatal clinics in India, this aspect is most neglected. The next most sensible period to assist and guide them to practice correct techniques would be the immediate postpartum period. In this pandemic, the anxiety levels of parents especially mothers have risen more rapidly. Among many queries and doubts that parents have during pregnancy, whether to breastfeed their baby or not is an important question that needs to be answered. As public health professionals, we have a great responsibility towards our society to guide them adequately.¹¹

METHODS

This cross-sectional study was conducted in two taluk hospitals namely, Karunagappally Taluk Head Quarters Hospital, Punalur Taluk Head Quarters Hospital of Kollam District.

There are 5 taluk hospitals in the Kollam district. They are Karunagappally Taluk Head Quarters Hospital, Sasthamkotta Taluk Head Quarters Hospital, Punalur Taluk Head Quarters Hospital, and Kottarakkara Taluk Head Quarter Hospital and Kadakkal taluk headquarters hospital. Out of the five Taluk hospitals, two hospitals were selected by simple random method. From the selected hospitals the mothers who were delivered during the COVID-19 pandemic that is from March 2020 was selected purposively. Ethical clearance for this study was obtained from the Institution Ethics committee, Rajiv Gandhi Institute of Public Health, and Centre for Disease Control at Bangalore.

The mothers who were coming to the immunization clinic for vaccination were asked for the MCP card to check the date of delivery and 50 from each Taluk hospital were selected using the lottery method for the study. The study population consisted of mothers who have delivered the child during the ongoing COVID-19 pandemic since 2020 March.

Inclusion criteria

Mothers who have delivered during the COVID-19 pandemic. Women who gave consent for the study.

Data collection tools

After taking informed consent, data were collected by interviewing the mothers using pre- designed, pre-tested, and semi-structured questionnaire which was for (i) socio-demographic, knowledge, and practice information was collected through a pre-structured pre-tested questionnaire (ii) The Iowa infant feeding attitude scale (IIFAS) which is a pre-designed pre- tested questionnaire for attitude related information.

Before the study permission was taken from the district medical officer and the superintendent of both the taluk hospitals. The study participants were informed about the purpose and procedure of the study and their consent was taken and were assured about confidentiality. The questionnaire was administered by hand and was requested to fill them and were collected in person from the respective taluk hospitals. The questionnaire consisted of four parts of which the first part consisted of socio-demographic variables which were having questions about age, religion, type of family, income, educational status, and parity and the second part consisted of knowledge which had 13 questions and the third part consisted of attitude which had constituted 17 questions and the fourth part consisted of practice related 11 questions. A scoring system with a score of one for each correct answer and zero for the wrong answer was given. 50 mothers from each hospital were taken after filtering the incomplete response from the mothers.

Statistical analysis

Statistical analysis was done using Microsoft Excel and SPSS 20 version. Descriptive analysis of obtained data was done. The categorical data were presented in the form of frequency tables along with percentages. The quantitative variable was summarized using mean±standard deviation with 95% confidence interval (CI).

RESULTS

The mean age of the participants was calculated to be 25.15 with a standard deviation of 2.883. In the knowledge of respondents, 99% knew that colostrum is the first breast milk. 83% of respondents knew that colostrum is important for the baby to maintain immunity. The majority of the mothers stated that burping should be done after each feed (90%). 85% of mothers agreed that exclusive breastfeeding should be done. 90% of the mothers agreed that they will be continuing feeding for 2 years. More than half of the participants stated that the mother should not feed the child when she has diarrhea (54%). About 65% thought that one should stop feeding when they start to wean (Table 2).

The attitude of the mothers showed that 50% disagreed that formula feeding is more convenient than breastfeeding. 80% thought that breastfeeding increases mother-infant bonding. More than 50% agreed that formula feeding is a better choice if the mother goes to work (75%). More than 70% thought that women should not feed in public places (77%). 76% agreed that breastfed babies are healthier than formula-fed babies. 91% opined that breast milk is the ideal food. More than 90% said that breastfeeding is more convenient than formula (92%) (Table 3).

DISCUSSION

This study explored the knowledge, practices, and attitude regarding breastfeeding in mothers who delivered during the COVID-19 pandemic. In the present study, 99% knew about colostrum and 83% knew that colostrum is important for the baby to maintain immunity, which is much higher compared to the study conducted in Wayanad.3 In the present study, 85% of the respondents were aware that exclusive breastfeeding should be done till 6 months of age which is like a study conducted in the Dakshin Kannada district.⁵

Most respondents in the study had good knowledge about breastfeeding and a larger part of them were aware of exclusive breastfeeding. This is similar to a study conducted by Vijayalakshmi et al.⁶

This study showed that in the practice of breastfeeding the pre-lacteal feeding was 64% which is like a study conducted in rural Uttar Pradesh.⁸ But it is much lesser when compared to another study conducted in a tertiary center in Kerala.⁹

Regarding the attitude of mothers about breastfeeding in the present study, it was explored 80% of mothers believed that breastfeeding increases mother-infant bonding, which is similar to another study conducted in rural areas of the Thrissur district of Kerala.¹⁰ In the present study 66%of mothers said that formula feeding is a better choice when the mother goes back to work and also 91% accepted that breastmilk is the ideal food.¹⁰

In the covid positive mothers in the emotional and mental wellbeing perspective, around 34% were having stress and tension. This was considered in a study in which it stated that breastfeeding decreases postpartum depression and should be continued.¹² In a study conducted in Poland, the pregnant and lactating mothers had stress and anxiety which is much higher compared to the present study.¹³ Another study conducted among Mexican women also explored that stress and anxiety were higher than in the present study.¹⁴ In the present study, it was found that mothers were scared to feed, and feeding was stopped or interrupted which led to increased stress and tension which was also seen in another study conducted in Turkey.¹⁵

In the context of the pandemic, as an impact of COVID-19 on breastfeeding, evidence, and fear of potential risks, the first recommendations of some international scientific societies, advised the isolation of positive covid mothers during childbirth and the puerperium. They also advocate avoiding skin-to-skin contact as well as separating and isolating the newborn.

Mothers strived to get support and had several barriers deriving from lockdown with some stopping breastfeeding before they were ready. Emotional support was an important factor which when was lacking lead to stress and tension in the breastfeeding mothers.

This study shows the significance of the COVID-19 pandemic which created stress and fear among the postnatal mothers, also this study was conducted in Kerala, a state with the highest literacy rates. However, the limitation of the study is that it was conducted in Taluk hospitals which involved lactating mothers hence, the findings of this study may not be representative of the situation of knowledge attitude and practice during covid in the entire community. The experiences of these women can be distributed to women in other states and the details may be relevant for midwives and other health care professionals active with childbearing women and their families.

CONCLUSION

The knowledge was not a determining factor for exclusive breastfeeding as the exclusive breastfeeding rate is still lower compared with the maternal knowledge. COVID-19 has also contributed to the reduction in exclusive breastfeeding due to stress tension, baby separation, and sick mothers. The results of the study show that the coronavirus pandemic has a notable capability for creating stress, tension, and fear, which has a negative emotional effect on mothers.

ACKNOWLEDGEMENTS

I would like to express my gratitude to all the participants and all others who helped and supported me 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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